Sunday, May 9, 2010

The Promotion of Breastfeeding and Impact on the Proportion Who Breastfeed: A Critique of the National Breastfeeding Campaign - Courtney Porter

Upon giving birth, mothers need to decide whether to breastfeed or to utilize formula in order to provide their baby with nutrition. Unless the mother suffers from one of the rare circumstances in which it would not be recommended, the optimal decision would be to breastfeed. According to research, benefits of breastfeeding can be seen within both the baby and mother (1-3). Breastfeeding is also economically beneficial as it costs less for families than paying for formula (1, 3).

The benefits of breastfeeding for a child are wide spread and seem to continue throughout development. Within the first several days after birth, the breast milk is considered colostrum, which has a different composition than mature breast milk (4). Colostrum contains a high concentration of vitamins, minerals, and antibodies, such as zinc, sodium, potassium, fat-soluble Vitamin A, and carotenoids. In addition the substance assists in the establishment of the bifidus flora within the digestive tract and may boost the development of the immune system.

In part due to colostrum, initial benefits of breastfeeding include lower rates of contracting and dying from otitis media, respiratory tract infections, bacteremia, diarrhea, botulism, urinary tract infections, necrotizing enterocolitis, and bacterial meningitis as compared to infants who are not breastfed (1, 3). Research supports more chronic benefits of breastfeeding as well, including reduced risk of obesity, insulin-dependent diabetes mellitus, ulcerative colitis, Crohn’s disease, hypertension, and allergic diseases (1-3). Children who have been breastfed also scored higher on motor and intellectual development assessments (1).

In addition to being beneficial for the child, breastfeeding can also benefit the mother. According to various research studies, “initiation of breastfeeding immediately after delivery stimulates the release of oxytocin, a hormone that helps to contract the uterus, expel the placenta, and reduce postpartum bleeding” (1). Women who breastfeed are able to lose the weight they gained during pregnancy quicker than those that do not (3). Breastfeeding decreases the risk of breast cancer before menopause and ovarian cancer (1, 3). It also delays the re-onset of ovulation which therefore increases the time between pregnancies.

Despite all of the short-term and long-term benefits of breastfeeding, all mothers who are able to breastfeed do not make the decision to do so. In 2003 as determined through the National Immunization Survey, the national rates of breastfeeding in the early postpartum period, at six months, and at 12 months were 72.6 percent, 39.1 percent, and 19.6 percent, respectively (5). The percent of mothers exclusively breastfeeding (without supplementing with formula, water, glucose water, etc.) at three and six months were 29.6 percent and 10.3 percent, respectively.

In order to increase the rates of breastfeeding, the United States Department of Health and Human Service’s Office of Women’s Health (OWH) in collaboration with the Advertising Council developed a National Breastfeeding Campaign (7). The goals for the campaign were based upon the Healthy People 2010 targets. The Healthy People 2010 Objective 16-19 goal was to “increase the proportion of mothers who breastfeed their babies: in early postpartum to 75 percent, at 6 months to 50 percent, at 12 months to 25 percent, exclusively through 3 months to 40 percent, and exclusively through 6 months to 17 percent” (6). The campaign focused on increasing the rate of breastfeeding in the early postpartum period to 75 percent and the rate at six months to 50 percent as well as emphasizing the importance of exclusively breastfeeding for at least six months (7). Though they wanted to increase breastfeeding within all mothers, the target population was first-time mothers who would not typically choose to breastfeed. The campaign was launched in June 2004 and ran until April of 2006 with a media campaign that included television ads, print ads, billboards, and radio spots

Critique of the National Breastfeeding Campaign

As discussed earlier, the benefits of breastfeeding make it the optimal choice for the infant and the mother. As the optimal choice, all women who are able to breastfeed should be doing so. Therefore, breastfeeding should be promoted and supported as the optimal choice in order to increase the proportion of able mothers who breastfeed. An effective public health intervention would achieve that goal and increase awareness about the benefits of breastfeeding. Though the National Breastfeeding Campaign was created with this goal in mind, it failed to do so. Three factors contributed to this failure, which were its basis on fear appeals and a negative approach, its failure to address other factors that cause women to not breastfeed, and its failure to market an appealing behavior besides health.

I. Based on Fear Appeals and Negative Approach

As part of the National Breastfeeding Campaign, two television advertisements were utilized to promote breastfeeding exclusively for six months. Within both commercials, women in their final trimester of pregnancy are engaging in behaviors dangerous to the health of the fetus. In one, two women are competing in a log rolling contest and working vigorously to remain on the log. “You wouldn’t take risks before your baby’s born” (7) comes across the screen and then “why start after” (7). Shortly after the text disappears, one of the women fall into the water as you hear the crowd gasp. The following announcement is then made: “recent studies show babies who are breastfed are less likely to develop ear infections, respiratory illnesses and diarrhea. babies were born to be breastfed” (7). In the other commercial, the same text and verbal announcements are made. Rather than seeing two pregnant women engaging in a log rolling contest, you experience a woman who appears to be in her final trimester of pregnancy riding a mechanical bull at a bar setting. The lady rides triumphantly for a short time before falling off to which the audience gasps and then cheers to her jumping up exuberantly.

Utilized in both commercials was a negative, fear-based appeal as the approach. The commercials leave one feeling as if not breastfeeding is as risky and harmful to an infant as a log rolling contest or riding a mechanical bull would be to a fetus. It paints such a negative picture of not breastfeeding that it incites fear and anxiety in the audience.

Recently, this method has become a popular approach used by social marketing campaigns. These commercials and others that utilize a similar approach use shocking visuals in hopes of gaining the attention of the targeted audience and stimulating them to alter their behavior in the desired way (8-11). Though focus groups have supported that they grab the attention of the audience, the commercial may leave the viewer feeling disturbed, fearful, and anxious.

For breastfeeding, generating anxiety within mothers is especially troubling as “breastfeeding is undermined by internalized stress” (12). Therefore if the fear appeal approach works as desired it may make it harder for women to breastfeed rather than to achieve its goal of increasing the proportion of women that breastfeed. In addition to feeling anxiety about breastfeeding, several studies have supported that maladaptive responses may be caused by fear appeals. According to the research, these responses are a coping method for the disagreeable feelings that arise as a result of seeing the negative, fear appeal. Some maladaptive responses are “avoiding or tuning out the message, blunting (failing to process the salient threat part of the message), suppression (failing to relate the threat to oneself), and counterargumentation (summoning arguments against the message’s veracity)” as determined by various studies (10). Rather than making the decision to breastfeed, the campaign may have caused women to become increasing afraid of harming their fetus or to not be able to realize that the risks associated with not breastfeeding was relevant to them.

II. Failure to Market Appealing and Desired Behavior

Also a part of the National Breastfeeding Campaign was several print ads used to promote exclusively breastfeeding for six months. An example ad shows two scoops of ice cream in a dish with cherries on top of each in order for them to resemble breasts. The text along the bottom of the advertisement reads “breastfeed for 6 months. You may help reduce your child’s risk for childhood obesity” (7). Each of the ads differed in the visual and the benefit stated, but followed the same general concept. Though different visuals and statistics are shown in each advertisement, the benefit of health is the sole promise marketed within each print ad.

As argued by the Marketing Theory, public health practitioners often try to market what they determine to be what the targeted audience should want and need (13). As with the case of the National Breastfeeding Campaign, improved health is often what the public health community determines to be important regardless of the little to no demand for it. In contrast to selling what the public health community believes is important; the Marketing Theory argues the need to take a different approach.

According to the theory, the steps of successfully marketing for a public health problem are the following: “(1) identifying the needs, wants, and core values of the target audience to define the product as beneficial to that audience; and (2) packaging and positioning the program or policy so that it reinforces the core values of the target audience” (13). The National Breastfeeding Campaign fails to base the two components of marketing campaign, its promise and the support for the promise, on these steps. Within its print ads, it solely markets health and utilizes data to market that promise which has been shown to be ineffective and unconvincing.

The campaign fails to provide the audience with a desirable behavior to change for. Framing should have been utilized in order to provide the audience with that desirable behavior. Without appropriate framing, the campaign failed to go beyond the health benefits to marketing for core values of Americans, such as freedom, autonomy, independence, family, and virility.

III. Failure to Address Other Factors

In addition to inappropriately utilizing a negative, fear appeal and failing to appeal to a desirable behavior, the National Breastfeeding Campaign failed to address other factors that influence whether a women breastfeeds or not. The campaign framed the issue to be a simple decision that mothers make or a simple weighing of the costs and benefits of breastfeeding. Research and data have shown that other factors contribute to the initiation and continuation of breastfeeding including socioeconomic status, race/ethnicity, age, and education level (5, 14).

According to the National Immunization Survey (NIS), in 2003 the rates of initiating breastfeeding, breastfeeding at six months, and breastfeeding at 12 months was lowest in non-Hispanic blacks as compared to other race/ethnicities (5). The rates of breastfeeding increased as the age of the mother increased as well as when the maternal education level increased. Similarly an increase can be seen corresponding to an increase in poverty income ratio with 63.4 percent of mothers at less than 100 percent poverty level ever breastfeeding as compared to 81.7 percent of mothers at more than or equal to 350 percent poverty level ever breastfeeding in 2003 (5).

In addition to sociodemographic characteristics influencing breastfeeding, the amount of family and community support plays a role in the decision to breastfeed. Family members and partners having a negative attitude about breastfeeding was considered a barrier to breastfeeding (15). Societies that were supportive of mothers and had generous maternity leave mandates had higher rates of breastfeeding, as supported by cohort studies (16). Other employment supports such as providing breaks for breastfeeding and making the work environment more friendly for women who breastfeed as well as allowing for more part-time work increased the proportion of women who breastfed.

Another societal factor that undermines breastfeeding attempts is the financial support given to hospitals and clinics by formula companies. Unless the hospital is denoted as a baby-friendly facility, formula companies provide hospitals with samples that are given to the mothers of newborns upon discharge and have advertisements throughout hospital facilities. In addition to the formula, the take-home gift bags given to parents are often sponsored by formula companies and include the products of the company (3, 12, 15).

“The campaign placed the burden of change on individual women rather than on the medical and cultural practices and societal structures that undermine their breast-feeding intentions and success,” argues Judy M. Hopkinson of Baylor College of Medicine (12). It is reasonable to assume that framing the issue in this way to put the entire burden on the mothers leads to more guilt in the mothers. Many times when a woman is unable to or does not breastfeed it is not simply a matter of knowing the benefits and weighing the pros and cons. As discussed, many other factors influence the behavior that were not addressed in the campaign. The campaign focused too much on the behavior of the individual rather than the societal and environmental structural factors.

Proposed Intervention for the National Breastfeeding Campaign

As the best nutritional option for an infant, breastfeeding should be performed whenever it is possible and feasible for the mother to do so. Though it is the optimal choice, the rates of breastfeeding in the early postpartum period, at six months, and at 12 months and the rate of exclusively breastfeeding for the first six months and 12 months of the infant’s life are lower than desired (as known by lower rates than the Healthy People 2010 targets).

The National Breastfeeding Campaign attempted to decrease the discrepancy between the national rates and the Healthy People 2010 targets, especially within the population of first time mothers who would not typically breastfeed. As with any public health intervention, the National Breastfeeding Campaign was not without flaws. As discussed earlier, three of the shortcomings are the following: its basis on fear appeals and a negative approach, its failure to address other factors that influence whether or not a mother breastfeeds, and its failure to market a desirable message besides health. Using an ecological approach that utilizes a positive message and incorporates principles of the Marketing Theory, the three shortcomings can be addressed.

I. Utilize a Positive Approach

As described previously, the two television commercials that were part of the campaign utilized shocking visuals in order grab the attention of the targeted audience. Though the commercials may have gained the attention of the audience, it also may have left them feeling fearful, anxious, and guilty. It may also have resulted in maladaptive responses being created in order to cope with the unpleasant feelings resulting from the shocking visuals. In some situations fear appeals may be an effective approach, but anxiety and stress undermine breastfeeding which undermines the campaign.

As opposed to the negative, fear appeals utilized in the National Breastfeeding Campaign, a positive approach and positive labeling should be used. The commercial and print ads should frame breastfeeding as positive and natural, as recommended by the Department of Health and Human Services (17). Within the Breastfeeding: HHS Blueprint on Action on Breastfeeding the Department of Health and Human Services recommends a “media campaign which presents images of breastfeeding as the normal way to feed infants in most places women and their infants go” (17).

The most effective way to utilize positive emotional appeal should be determined through focus groups of pregnant women and mothers. Possible positive emotions that can be used are compassion, joy, humor, and empathy (8). As supported by research, these emotions may be able to grab the attention of individuals who were overly familiar with similar campaigns and therefore no longer pay attention as well as to allow individuals who did not consider the issue relevant to them to reconsider this idea.

II. Incorporates Marketing Theory Principles

The print advertisements, which were described earlier, marketed the benefit of health as being an outcome of breastfeeding. According to the Marketing Theory, public health practitioners often attempt to market what they believe to be important for the society, such as health. As is often the case with solely marketing improved health as the benefit of a policy or program, the product that the public health community believes society should want has little or no demand within society.

Utilizing principles of the Marketing Theory, the proposed intervention would sell core values rather than just the benefit of improved health. By marketing core values, the deepest aspirations that people have would be sold. The core values would provide enough incentive for individuals, especially mothers, to change their current behavior. These core values include family, America, freedom, youth, virility, strength, an identify, fun, happiness, laughter, and joy. In order to support these core values being marketed, visual images will be utilized. This is vastly different from the statistics and data that supported the promise of health within the National Breastfeeding Campaign. The visual images should be supportive, positive, and show the audience that the promise being made is real. As discussed previously, the media campaign should utilize images that portray breastfeeding as a natural, desirable, and achievable behavior.

III. Address Other Factors, Such As Societal and Environmental Factors

The National Breastfeeding Campaign was an individual-level approach that did not address other factors that influence whether or not a mother breastfeeds. Based on statistics and research, socioeconomic status, race/ethnicity, age, education level, family support, and community support play a role in whether or not a mother initiates breastfeeding and continues to breastfeed. As the campaign did not address any of these many factors and focused the burden on the individual mother, feelings of guilt may have arisen in mothers who wanted to breastfeed and were not able to or mothers who did not want to breastfeed due to societal and/or environmental factors.

Utilizing a broad, population (group)-level approach such as an ecological approach, the proposed intervention would be able to address the societal and environmental factors that influence initiation and continuation of breastfeeding. An ecological approach takes a comprehensive perspective (18). While it continues to consider the relationship between mother and infant as well as family, the approach also considers the community, healthcare delivery system, societal and cultural influences (the mesosystem and exosystem of the family). To implement an ecological approach, many layers of interventions would need to occur simultaneously and throughout several sites. In addition to simultaneous implication, it is necessary to have frequent and open communication with all individuals involved in the implementation of the layers of intervention in order to seamlessly provide the services and supports of the program.

Included in the ecological approach would be the promotion of the Baby Friendly Hospital Initiative (BFHI) (19). Within the United States, the BFHI is organized through Baby-Friendly USA and is sponsored by the United Nations Children’s Fund (UNICEF) as well as the World Health Organization (WHO). This initiative aims to provide mothers with support, information, skills, and confidence in their ability to initiate and continue breastfeeding. In order to become certified as a Baby-Friendly Hospital, the facility must go through the “Ten Steps to Successful Breastfeeding” (19). These steps include educating pregnant women about the benefits of breastfeeding, allowing babies to remain in the same room as mothers, and assisting the initiation of breastfeeding within one hour of birth. Hospitals must also discontinue receiving free samples and other financial assistance from formula companies.

Another aspect of an ecological model would be to encourage (or even require) employers to create an environment that is friendlier to employees engaging in breastfeeding. Some policies to create such an environment would include providing breaks for breastfeeding and allowing for more part-time work. Employers would support and promote breastfeeding among their employees.


With the many short-term and long-term benefits for the infant and the mother, breastfeeding is the best choice of nutrition for infants. In order to promote breastfeeding among mothers, especially first-time mothers who would otherwise not engage in the behavior, the United States Department of Health and Human Service’s Office of Women’s Health (OWH) in collaboration with the Advertising Council developed a National Breastfeeding Campaign. The campaign ran two television commercials, circulated print advertisements, put up billboards, and held radio spots for two years, but suffered from shortcomings. Three of those shortcomings were the following: its basis on fear appeals and negative approach, its failure to market an appealing and desirable behavior, and its failure to address other factors that influence whether or not a mother breastfeeds. Utilizing an ecological approach that incorporates a positive message and principles of the Marketing Theory, the three shortcomings can be addressed and overcome.


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