Monday, May 10, 2010

The National Breastfeeding Awareness Campaign: Failure to Contextualize Individual Behavior Change – Eloesa McSorley

In June 2004, the Office of Women’s Health, as part of the US Department of Health and Human Services (USDHHS), launched the National Breastfeeding Awareness Campaign (NBAC). The campaign was a result of directed funding to increase the proportion of women who initiate breastfeeding with their first infant and who exclusively breastfeed during the first six months post partum (1). This objective was articulated in Healthy People 2010 as to increase the percentage of women that breastfed in the early postpartum period from 64% (1998 baseline) to 75% by 2010 (2). Additionally, objectives of percentage increases were put forth for the rate of breastfeeding at 6 months (from 29% to 50%) and at 1 year (from 16% to 25%) (2).

With these goals in mind, the USDHHS Office of Women’s Health produced the HHS Blueprint for Action on Breastfeeding (3). The report evaluated the state of breastfeeding in the United States and established four specific goals that would lead to fulfillment of the Healthy People 2010 objective (3). With the charge of the report the Office of Women’s Health established the National Breastfeeding Awareness Campaign. The overall goals of the Campaign were those established in the Healthy People 2010 document (1). The campaign had two main components: a nationwide media outreach campaign and sixteen community based demonstration projects (1). Both components sought to increase rates of breastfeeding through empowering women to commit to breastfeeding (4). The Office of Women’s Health worked with the Ad Council to create and disseminate the campaign which ran through April 2006 (5).
The campaign, though well crafted and supported by valid and thorough scientific research, failed to fulfill its goals. I argue that this is partially due to three problems in t he campaign. First, the campaign failed to include all relevant information necessary for women to make an informed decision regarding the decision to breastfeed, in particular information regarding infant formula. Second, the campaign failed to consider all of the stages of change that a woman would go through to initiate and continue breastfeeding. And finally, the campaign only sought to address women themselves, ignoring others that may influence a woman’s decision and capacity to breastfeed, and failing to appropriately contextualize the health behavior.

I. Failure to fully implement the Health Behavior Model

The nationwide media outreach component of the NBAC sought to recast the benefits of breastfeeding to have a greater perceived consequence (4). The health related behavioral principals that underlie this campaign strategy come from the Health Belief Model (HBM) (5). The HBM views health related behavior change as related to an individual’s perception of the severity of risk associated with not changing behavior, along with perception of their individual susceptibility to the risk (6). Additionally, the HBM posits that people will also consider the potential benefits of implementing a behavior change and the likelihood that they can implement the change (i.e. what barriers they face to changing) (6). A critical flaw of implementation in the nationwide campaign was that the campaign only told half of the story about risk, and therefore failed to fully implement the HBM, underutilizing its potential for change in this situation.

The NBAC used a strategic implementation of framing via the print portion of the nationwide media outreach campaign to invite expectant mothers to think about breast-feeding as a risk reduction strategy (i.e. to think about not breastfeeding as imposing a risk upon a child). They cleverly used images associated with the risk being addressed portrayed in such a way as to represent breasts. Two dandelions were used to represent a possible decrease in respiratory illness in breastfed babies, ice cream scoops with cherries on top represented a decreased likelihood of childhood obesity in children exclusively breastfed for the first six months of life, and otoscopes represented a decrease in the likelihood of childhood ear infections obtained by exclusive breastfeeding (1). Public Service Announcements (PSAs) designed for television portrayed pregnant women engaging in activities that would be universally understood to carry a substantial risk of injury to a fetus, such as log rolling and riding a mechanical bull, and were accompanied by the text, “You wouldn’t take risks before your baby was born. Why start after. Breastfeed exclusively for 6 months.” (1) Both media campaigns were clever, catching and humorous. Additionally, they both encouraged further inquiry into the subject.

However, these ads were created and disseminated in the context of a moms and future moms having a perception of breastfeeding as the “ ‘ideal,’ not the standard” (6). This begs the question: what, then, is the standard? Of course, the answer to this is that the majority of those mothers that are not exclusively breastfeeding their infants up to six months or a year postpartum, are feeding them infant formula. Knowing this, a goal of the campaign was to establish breastfeeding as the standard, as opposed to the ideal (6). The statements about risk that are included in the print and TV ads are lacking the essential information that increased risk is not only associated with women not breastfeeding, but, logically, with women instead using baby formula as a primary source of nutrition for their infants. There have been many critiques made of the Health Belief Model, one being that it assumes that individuals act rationally and empirically when presented with a risk benefit analysis of potential health behavior implementation (7). However, before addressing such an aspect of a public health intervention based on the HBM, one must observe a well constructed intervention based on the HBM in the first place. NBAC not only omits discussion and information about risks associated with using baby formula, they also fail to embrace an opportunity to remove clout from (or insert uncertainty into) the perceived benefits of using baby formula. By leaving this out of its ad campaign, the NBAC fails to give consumers of the ads adequate information about risks and benefits of breast feeding in contrast to the risk and benefits of the oft used replacement, baby formula.

Of course, the NBAC does imply that breastfeeding is associated with health benefits and reduced risks to health compared to baby formula, simply by addressing the risks associated with not breastfeeding. Doing this does, in a sense, tie risks to formula feeding, but by addressing formula feeding in this indirect way, it places the context in which a mother makes a decision to breastfeed or formula feed, unrelated to a risk/benefit analysis, in a neutral place. The environment in which mothers make these decisions is far from neutral. Barriers to breastfeeding have been cited by a variety of studies and include social environment, conflicts with employment, inadequately trained hospital support staff, among others (8-10, 3). These types of barriers can and are being addressed through media campaigns, changes to policy in work settings and training programs. Such interventions all have to do with creating an environment in which a mother feels that it is both the right choice and the accessible choice to breastfeed (3). However, the other side of the environment in which a mother initiates and continues to breastfeed or does not, is one that is heavily influenced by the marketing and influence of formula companies that exploit the existence of the barriers stated above in order to make formula feeding an acceptable and an easy choice.

The infant formula is an $8 billion a year industry, and as it is an industry, there is strong investment in seeing that products are consumed (11). Formula companies use both direct to consumer advertising, as well as advertising and distribution of free samples in hospitals and other birthing environments. Without getting into business ethics or the impact of consumer or doctor marketing, what makes the story of the influence of the infant formula industry on the NBAC campaign unique is the emergence of information that the industry, upon reviewing the original marketing plans of the Ad Council, exerted pressure and influence to have certain ads withdrawn that did more directly address breastfeeding in comparison to formula feeding (12). In particular, original manifestations of the ads were to include specific statistics about increased risk associated with formula feeding and also were to include information on leukemia and diabetes (12). The change in stance of the NBAC only goes to highlight that an understanding was at hand about the strength of a message making a comparison between the benefits and risks and breastfeeding versus infant formula. To water down the message is to remove agency from expectant mothers in their capacity to make decisions, all else equal, given the most complete information.

II. Implementation strongly addressing only initial stages of change

Ideally, the transtheoretical of behavior change can describe the process that a woman may go through in her decision to breastfeed if she is exposed to the NBAC. In her stage of precontemplation, she doesn’t know how she will feed her infant after it is born, perhaps she hasn’t really thought about it yet. She may then be exposed to a television or print ad produced by the campaign and may gradually move into the contemplation stage, wherein she decides that she will breastfeed her baby. Next she maybe will tell her partner, her doctor and her family of her plans, perhaps buy a breast pump – this is all part of the preparation stage. Immediately post-partum, a woman would, ideally, initiate the action and begin breastfeeding her child. She would then maintain this behavior through at least the first six months post partum (7).

The NBAC has two distinct, but related goals. It aims to increase the proportion of women who breastfeed and it aims to increase the proportion of women who breastfeed exclusively for the first six months postpartum (1). Paramount to the fulfillment of these goals is that women initiate breastfeeding immediately postpartum (13). The concern with the implementation of a campaign the focuses exclusively on awareness is that it envisions its primary effect to be had on women in either the precontemplation or contemplation stage. It doesn’t address aspects of planning or steps that a women might take to plan for breastfeeding. It doesn’t address the myriad of elements that go into the crucial moment that a women “decides” to breastfeed her baby immediately post-partum. And it doesn’t address ways in which women can continue to breastfeed, considering the environment in which breastfeeding is going to realistically be carried out.

In terms of addressing the initiation of breastfeeding immediately postpartum, though a new mother may be aware of the benefits of breastfeeding, and the risk associated with not breastfeeding, the risk benefit equation that she is theoretically weighing is considered at a key moment defined by the extremely emotionally and physically demanding act of giving birth. There is a likelihood that she will cease to think rationally about the decision in that moment, and “decide” to not breastfeed. Or, she may even think very rationally and consider how exhausted she is, how there are no nurses around to help her breastfeed, how, perhaps, despite all those adds about risk and not breastfeeding, she is a new mom and doesn’t know how to breastfeed and is worried she may do it wrong. The NBAC campaign relies solely on the idea that mothers will be so concerned with the potential risks of not breastfeeding that they will do whatever is necessary to initiate breastfeeding. The campaign, self-styled as an awareness campaign, fails to give moms ideas for how to begin breastfeeding, ignoring a preparation stage. It also fails to address the importance of initiation in the first moments of a child’s life, an aspect crucial to mothers moving into the action, and then maintaining the health behavior.

III. Changing the perception of breastfeeding among many social levels

By implementing a risk-based awareness approach to its campaign, the primary target of the NBAC is expectant mothers. In making expectant mothers the primary target of the campaign, the framers of the campaign are making an assumption that mothers are the people that would 1) be most concerned with their expected child’s health and well being, 2) be the individuals who will carry out the act of breastfeeding and 3) initiate the act of breastfeeding in a self-determined way, according to their will. Secondary to targeting mothers, the ad campaign attempts to indirectly address co-parents, recognizing that the father, in particular, plays an important role in a mother’s decision to breastfeed (5). By changing the perception of breastfeeding from the “ideal” to the “standard,” the campaign attempts to establish and normalize breastfeeding as the standard for the co-parent, thereby fostering a sense of acceptance and support among in the family structure so that mothers will feel comfortable breastfeeding (5).

This aspect of the campaign speaks to individual behavior change alongside a primary interpersonal relationship that will affect child-rearing choices. However, it does not address other relationships and obstacles that a mother contends with when evaluating support for her decision and capacity to breastfeed. Specifically, the ad campaign does not do enough to normalize breastfeeding at all levels of the socio-ecological framework, nor does it do enough to disrupt a static notion of breastfeeding as tied to limiting perceptions femininity and motherhood.

The socio-ecological framework acknowledges that the social environment is made up of multiple levels of influence that effect health behavior, including intrapersonal, interpersonal, institutional or organizational, community and public policy factors (14). The NBAC targeted its efforts to the intrapersonal and interpersonal level of this framework, and largely ignored addressing efforts and awareness at the institutional/organizational, community or public policy level. This is particularly damaging to a breastfeeding awareness campaign, because there are a variety of environments that a women could potentially breastfeed in, in which she is discouraged from doing so due to social norms. Additionally, by only targeting the intrapersonal and interpersonal relationships that could affect a mothers decision or capacity to breastfeed, the ad campaign does not create sufficient space in which it could have begun to restructure notions that are held about breastfeeding and notions and images that are portrayed related to breastfeeding throughout society. In their study on the factors that determined infant-feeding practices, McIntyre, Hiller and Turnbull (1999), found that a primary reason that women gave for not breastfeeding was potential embarrassment. The HHS Blueprint for Action on Breastfeeding noted that efforts were needed to address the social perceptions of breastfeeding and the subsequent social support that mothers had in their endeavor to breastfeed. The NBAC, despite its clever tactic for the print portion of the campaign, may even reinforce the idea that breastfeeding is something to be done in private, that breasts, as a vehicle for infant sustenance, should be hidden. By using images that are not, in fact, breasts and by removing women completely from its print campaign, the NBAC reinforces the idea that breastfeeding itself is too lewd, too exposed, to convey in a print advertisement.

Related to the fact that the campaign only addressed intra- and interpersonal aspects of behavioral influence, is the fact that the campaign does not attempt to change normative ideas about breastfeeding generally, nor ideas that are tied to limited and limiting notions of motherhood specifically and of womanhood, more broadly. By placing the onus of responsibility in breastfeeding initiation on the mother and by excluding direct images of women breastfeeding, the campaign reinforces a notion that breastfeeding is an exclusive act between mother and child and an act that is private, and should be kept private. While on the surface, it is true that the actual act directly involves two parties, the mother and the baby, reinforcing this notion of exclusivity and privacy recalls generations of public images related to breastfeeding that portray breastfeeding as a concealed, near spiritual act, that essentializes motherhood as something characterized by the intense caring and nurturing feelings that we expect mothers to have towards their babies when engaged in this act. As Rebecca Kukula notes, the imagery shows “mother and infant…locked into a dyadic and private relationship of mutual attention that excludes the rest of the world” (15). The portrayal of this relationship (or the fact that the NBAC campaign recalls it) reinforces ideas about motherhood and femininity that do not coincide with the complex world that mothers live in where they may have to breast feed at work, in a store, or while doing another task that any woman has the capacity to be involved in. The idea that breastfeeding is the be all end all of womanhood and of motherhood needs to be challenged. Furthermore, the fact that humor is tied into the imagery of breasts, simultaneously makes breasts themselves more one dimensional (i.e. private) and also reinforces social norms about objectivity related to breasts that create social spaces hostile to breastfeeding, viewed as part of female sexuality, in the first place.

Proposed intervention:

The National Breastfeeding Awareness Campaign had many strengths, but ultimately was lacking in key areas that would have given it more widespread and significant success. There are specifics ways in which amplification and adjustment of the campaign could be implemented to addresses the specific areas of weakness critiqued above. For a proposed intervention, I will focus on such amplification as opposed to designing a multifaceted campaign that could address not only awareness and understanding of breastfeeding, but also policy implementation that would facilitate and encourages breastfeeding among women in hospitals and in places of employment, acknowledging that for uptake of breastfeeding on a larger scale, such policies are essential (3). Directly answering the critiques discussed above, I put forth three suggestions for amplification and adjustment to the campaign. First, the campaign should include information about risk reduction via breast feeding compared to baby formula, while also removing neutrality from baby formula and the baby formula industry and placing it within the context of a business with a target audience. Second, the campaign should increase ad space and information to hospitals where women are giving birth. This will also increase campaign exposure to key individuals that will influence a mother’s decision and capacity to begin breastfeeding, so that she will have more potential to implement early initiation – a predictor for future breastfeeding and exclusive continuation of breastfeeding. Finally, the campaign should broaden its scope to target diverse members of the community through portrayal of diverse manifestations of motherhood and breastfeeding. These three amplifications and adjustments to the NBAC would build upon it s original structure to have a more widespread effect on changes in behavior and attitudes related to breastfeeding.

Defense I: Acknowledging alternatives to breastfeeding

If as a premise for changing behaviors related to breastfeeding, we assume that giving individuals (mothers in particular) information about the risks and benefits of breastfeeding, it is essential that we not withhold information critical to making an informed decision. By framing the issue of providing nutrition and sustenance narrowly to include only breastfeeding, the NBAC fails to acknowledge the oft used alternative, which is using baby formula. The new campaign should not only compare health outcomes, in a direct way, of breastfeeding versus formula feeding, but should also portray information about motives of formula feeding companies (i.e. profit).

In a study by Nommsen-Rivers, Chantry, Cohen and Dewey, comfort with the notion of formula feeding was the strongest (negative) predictor in a mother’s intention to breastfeed, compared to exposure to breastfeeding, comfort with ideas of breastfeeding and breastfeeding self-efficacy (cite). Specifically, Afriacn-American women were more comfortable with formula feeding and less comfortable with breastfeeding than their white and Hispanic counterparts (16). This is of particular importance, as African-American women are much less likely to breastfeed than other racial and ethnic groups, showing lower rates of both initiation and continuation (13).

Comfort with formula feeding can be disrupted by portraying scientifically supported information about the increased risks associated with formula feeding. Additionally, apart from increased risk to a child’s long term health, neutrality can be taken away from formula feeding by directly addressing the business aspect of the formula industry. This could be done in a clever way, comparing the for-profit aspects of formula feeding to the non-profit aspects of breastfeeding. Or the fact that the formula industry is an $8 billion dollar industry could be contrasted with the money and resources that go into the “breastfeeding industry.” This could be done directly by talking about the amount of money and resources that go into the actual campaign alongside other campaigns and maternal health interest groups, or it could be done indirectly by making a comparison to the “production capacity” of a woman’s breasts.

Defense II: Targeted timing and support of intervention

The second adjustment to the campaign would be to increase ad space to places that women are giving birth so as to target women closer to the moment of parity, and to target health care professionals that are an important source of support for women that may breastfeed. Additionally, the campaign should address behavioral change methods not only related to risk, but also related to action and continuation.

While increasing awareness of breastfeeding and of risks associated with not breastfeeding does directly address individuals in the precontemplation and contemplation stages of change, and even indirectly will affect people in further stages and in relapse, more decisive messages need to be implemented to prepare women to breastfeed, to move women into action, and to encourage continuation. Information should be provided to women regarding how she might feel when she first gives birth, and relative to that, how important it is to initiate breastfeeding as early as possible, if not immediately. Included in this information should be data on why breastfeeding in the first days of newborn life is particularly important for continued health and well-being (3).

Continuation of breastfeeding is already somewhat addressed in the current campaign, making a point of stating that breastfeeding should be done exclusively in the first 6 months of life (1). Continuation is very dependent on a mother’s work environment and support system (3). While these aspects can be addressed through policy in initiatives, continuation can also be addressed by including information in ads about how women can integrate breastfeeding into their lives: perhaps showing an actual picture of a women breastfeeding while working, or of a breast pump and some line of text about how giving babies breast milk can manifest in diverse ways.

Defense III: Normalizing of breastfeeding among all community members

A critical fault of the NBAC is that it does not appropriately or adequately consider the social context in which women breastfeed and as such does not attempt to change social norms about breastfeeding. As discussed above, the campaign only attempts to influence behavior change at intrapersonal and interpersonal levels, ignoring that these behaviors, especially significant with behaviors related to breastfeeding, are influenced by all levels of a socio-ecological model.

Particularly useful to an evaluation of current breastfeeding imagery and social perception of breastfeeding and to the development of new campaigns that attempt to change norms is the implementation of theory related to gender and power. In applying the theory of gender and power to a health behavior, we are drawn to consider what the risk factors are, created by historically unequal and differential perceptions of gender related to power, for a woman to engage in “harmful” health behavior (17). In other words, what are the factors that women face, determined by unequal power structures, that put her at an increased risk to not breastfeed? This, of course, has been stated in more benign ways, usually within the context of discussing barriers to breastfeeding. However, it is critically important to break down these barriers with an understanding of their social and historical roots in the relegation of women to a domestic sphere, the view of women as solely mechanisms of reproduction only, and sexism and objectification of women’s bodies. While this is no small task, a breastfeeding campaign that considers such a strategy could begin to reshape how society at large, and mother’s in particular, think about breastfeeding.

The sexual division of labor is particularly important in considering a women’s capacity to breastfeed in that policy may not be in place to allow her to breastfeed. The baseline from which policy is created is one in which the normative action by employers is not to consider roles of parenthood that women take on in the professional sphere, because they have historically been placed in a domestic sphere. While policy implementation is important, more significant is changing perceptions of breastfeeding as private and domestic to normal, diverse and professional. The campaign can address this by showing images of women using a breast pump at work. This could influence not only women in their self-efficacy to continue breastfeeding, but also workers at large to feel normal about such an action.

It will be important to show all types of women breastfeeding in a variety of situations. Kukla points out that two authoritative sources on breastfeeding, the American Academy of Pediatrics breastfeeding guide (AAP 2002) and the book What to Expect When You’re Expecting (Murkoff et. al 2002), are both resources that do not include images of women of color breastfeeding. Furthermore, images usually associated with breastfeeding show women that are “able-bodied, conventionally pretty and feminine, normally shaped… and endowed with normal-sized breasts” (15). This is especially shocking given the low rates of breastfeeding among African-American women, and reinforces the idea that if you are not the normative image of femininity or of a mother, then perhaps breastfeeding is embarrassing. An ad campaign needs to balance its message of breastfeeding as important to the health of the mother and the baby while not making it the defining characteristic of motherhood or womanhood, to give it weight, but in the context of the complex personal and social material that make up every woman. To understand how to change concepts of breastfeeding, the context of breastfeeding must be understood: both the physical reality (breastfeeding in work cloths or while engage in other activity) and the theoretical interpretation (as part of a social environment influenced by gendered power relationships and sexism). Then the portrayal of breastfeeding must reflect this reality, the ideal being that the health behavior can be achieved in the context, thereby changing the context.

Works Cited

1. Office of Women’s Health. National Breastfeeding Campaign. Washington DC: US Department of Health and Human Services.
2. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.
3. U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. 1ed. Washington, DC: U.S. Department of Health and Human Services, Office on Women’s Health, 2000
4. Office of Women’s Health. Presentation on Breastfeeding Campaign with Campaign Research Findings. Washington DC: US Department of Health and Human Services.
5. Haynes, SG. (2006, April). Breastfeeding and Public Opinion: Before and After the Launch of the National Breastfeeding Awareness Campaign. Presented at the 134th Annual Meeting and Exposition of the APHA, Boston, MA.
(accessed from
6. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
7. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
8. McIntyre E, Hiller JE, Turnbull D. Determinants of infant feeding practices in a low socio-economic area: Identifying environmental barriers to breastfeeding. Australian and New Zealand Journal of Public Health 2008; 23 (2): 207-209
9. Barber-Madden R, Petschek MA, Pakter J. Breastfeeding and the working mother: Barriers and intervention strategies. Journal of Public Health Policy 1987; 8 (4): 532-541
10. Dobson B and Murtaugh MA. Position of the American Dietetic Association: Breaking the barriers to breastfeeding. Journal of the American Dietetic Association 2001; 101 (10): 1213-1220
11. National Resources Defense Council. Issues: Health; Healthy Milk, Healthy Baby. Washington, DC: National Resources Defense Council.
12. Peterson, M (2003, December 4). The media business: Advertising; Breastfeeding ads delayed by a dispute over content. New York Times. Retrieved from
13. Centers for Disease Control and Prevention. (2010). MMWR weekly: Racial and ethnic differences in breastfeeding initiation and duration, by state – National Immunization Survey, United States, 2004-2008. Retrieved April 28, 2010 from:
14. Schneider MJ. Introduction to Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2006.
15. Kukla R. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia 2006; 21(1): 157-180.
16. Nommsen-Rivers LA, Chantry CJ, Cohen RJ, Dewey KG. Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeeding Medicine 2010; 5(1): 25-33.
17. Wingood GM, DiClemente RJ. The theory of gender and power: A social structural theory for guiding public health interventions (Chapter 3). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp. 313-346.

Works Consulted

-Bakalar, N (2010, April 19). Despite advice, many fail to breastfeed. New York Times. Retrieved from
-Chatterji P and Brooks-Gunn J. WIC participation, breastfeeding practices, and well-child care among unmarried, low-income mothers. American Journal of Public Health 2004; 94(8): 1324-1327
-Fein SB, Labiner-Wolfe J, Shealy KR, Li R, Chen J, Grummer-Strawn LM. Infant feeding practices study II: Methods. Pediatrics 2008; 122: S28-S35
-Grummer-Strawn LM and Shealy KR. Progress in protecting, promoting, and supporting breastfeeding: 1984-2009. Breastfeeding Medicine 2009; 4: S31-S39
-Merewood A and Heinig J. Efforts to promote breastfeeding in the United States: Development of a National Breastfeeding Awareness Campaign. Journal of Human Lactation 2004; 20 (2): 140-145
-Wolfe JH. Low breastfeeding rates and public health in the United States. American Journal of Public Health 2003; 93(12): 2000-2010

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