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.

References

1. Clinical study supports benefit of breastfeeding support for obese women. PhysOrg. April 15th 2010. http://www.physorg.com/news191417182.html

2. Artis, Julie E. Breastfeed at your own risk. Journals of the University of California Press. 2009. Vol. 8 No. 4. Pages 28-34

3. Chen, Yi Chun. Effects of work-related factors on the breastfeeding behavior of

working mothers in a Taiwanese semiconductor manufacturer: a cross

sectional survey. BMC Public Health. 2006. 6:160

4. DeFleur, Melvin L and Ball-Rokeach, Sandra J. Socialization and Theories of Indirect Influence (pg. 202-227). In: Theories of Mass Communication. Fifth Edition. White Plains, NY: Longman Inc, 1989.

5. Edberg, Mark. Individual Health Behavior Theories (pg 35). In: Edberg, Mark. Essentials of Health Behavior. Washington, DC:Jones and Bartlett Publishers, 2007.

6. Govtrack. H.R.2819:Breastfeeding Promotion Act of 2009. http://www.govtrack.us/congress/bill.xpd?bill=h111-2819

7. Haynes, Suzanne G. Evaluation of the National Breastfeeding Awareness Campaign (Babies Were Born to be Breastfed): Is Risk Susceptibility Associated With Higher Breastfeeding Rates? APHA Scientific Sessions. 2007. Abstract #165580

8. Jones, Camara Phyllis. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health. 2000. 90:8. pg. 1212

9. Kendall-Tackett, Kathleen. Breastfeeding and the Sexual Abuse Survivor. Journal of Human Lactation. 1998. Vol. 14 125-120.

10. Kukla, Rebecca. Ethics and Ideology in Breastfeeding Advocacy Campaigns. Hypatia. 2009. Vol. 21. Issue 1. Pages 157-180

11. Massachusetts Breastfeeding Coalition. Breastfeeding and Public Health. Weston, MA. http://docs.google.com/viewer?a=v&q=cache:BsMVGcIKzQsJ:massbreastfeeding.org/pdf/onePageSumm.pdf+breastfeeding+public+health+programs&hl=en&gl=us&pid=bl&srcid=ADGEESjlBnyK2TDqogu6BpQe9czp6aZqpw8zx2Kibii9lsXM_WikuWR75CDnPklMJmx_2jqvdcPwXxrkDsY0qY4W8nPyocpYo4EHybcf5AwRBecbV_hdEKZWJld0mk7y1QL_WY837bjr&sig=AHIEtbTCoPxKictqRlP3AJ8uf5c7eg_iKw.

12. Norsigian, Judy. Promoting Breastfeeding Takes More than Exhortations. The Politics of Women’s Health. Chapel Hill, NC. 2007. http://www.ourbodiesourselves.org/book/companion.asp?id=31&compID=135

13. Office of Disease Prevention and Health Promotion. Healthy People 2010. http://www.healthypeople.gov

14. Office on Women’s Health. National Breastfeeding Campaign. http://www.womenshealth.gov/breastfeeding/programs/nbc/

15. Parlimentary Office of Science and Technology. Health Behaviour. Postnote. 2007. Number 283.

16. Pugliese, Anne. Breastfeeding in Public. New Beginnings. 2000. Vol. 17 No. 6 p.196-200

17. Roth, Michelle. Could Body Image Be a Barrier to Breastfeeding? Leaven. Vol. 42 No.1 pp. 4-7.

18. Salazar, Mary Kathryn. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal. 1991. Vol 39, No. 3.

19. Siegel, Michael. Class Lecture. SB721. Spring 2010. February 11, 2010.

20. Siegel, Michael. Class Lecture. SB721. Spring 2010. March 18, 2010.

21. Wingood, Gina M. and DiClemente, Ralph J. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions (pgs 313-340). In: DiClemente, Ralph J; Crosby, Richard A and Kegler, Michelle C. Emerging Theories In Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley and Sons Inc., 2002

22. Wolf, JB. Is breast really best? Risk and total motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law. 2007

The Patient Protection and Affordable Care Act Overlooking the Implicit Needs of a Mother and Infant – Andrea DiNetta

The Patient Protection and Affordable Care Act (PPACA) was recently passed by Congress to address important issues surrounding health care in the U. S. One little known section of this bill contains a directive that attempts to meet one of the needs of new mothers and their infants, breastfeeding. Breastfeeding has been established as one of the most valuable contributions to infant health. The U.S. Department of Health and Human Services and World Health Organization both recommend exclusively breastfeeding infants up to 6 months of age. Components in breast milk have been found to have immune enhancing benefits, which reduce the rate of infant morbidity and mortality. There has also been consistent research showing that a breastfed infant’s neurocognitive development is accelerated compared to non-breastfed infants (1). The mother of the child also reaps benefits from breastfeeding. Increased post-partum weight loss and decreased risk of pre-menopausal breast cancer has been documented among the benefits. Some research suggests that breastfeeding mothers may also reduce their risk for ovarian cancer, osteoporosis and coronary heart disease (1).

The potential monetary savings in breastfeeding can be estimated at $1 billion dollars of savings from four major types of childhood illness that are believed to be preventable through breastfeeding. Each year non-breastfed infants cost the healthcare system $291.3 million for infant diarrhea, $225 million for respiratory syncytial virus, from $9.6 to $124.8 million for insulin-dependent diabetes mellitus, and $660 million for otitis media. Moreover, the intellectual gains of a breastfed infant, even though they cannot be precisely calculated, do have a significant impact on society as a whole. Expanding intelligence across the nation can make our country more advanced, which in turn will help the world grow with new technologies and progress in all areas of life (2).

With these statistics in mind, the new health care law contains an initiative to increase the human milk consumption of infants by targeting working mothers. With so many women in the workforce today, the government has chosen to address the needs of new mothers at their place of employment. Approximately 70% of mothers with children under three years old, work full time (3). Section 4207 in the PPACA states that companies with over 50 employees must allow mothers “reasonable break time” to express milk during work hours, until their infant is 1 year old (4). The PPACA attempts to address the importance of breastfeeding newborns by mandating lactation breaks in the workplace.

Applying Maslow’s Theory of Human Motivation, one can discover the implicit faults of this policy. Maslow’s theory recognizes that in addition to basic physiological and safety needs, the human requires a sense of love and belonging, self-esteem and self-respect, and finally, self-actualization or full potential. While offering mothers and newborns a basic physiological solution, the PPACA it does not address the other needs defined in Maslow’s theory, the psychological needs of the new mother or the psychological needs of the infant.

The PPACA intervention fails to address many of the actual needs of the mother and the infant in several ways. First, mothers may feel they have to return to work too soon and they have experienced more severe psychological stressors than those who wait (5). Secondly, the bond the mother creates through direct breastfeeding is too valuable to neglect and creates motivation in the mother for more breastfeeding (6). Lastly, the act of breastfeeding provides the physical comfort of a mother’s touch and a safe environment in which the infant can thrive (7).
Criticism #1:

According to Maslow’s Hierarchy of needs for self esteem, new mothers have a need to view themselves as having attained a very important role in society. Self-esteem is achieved through feelings of adequacy, confidence, and achievement (8). Governments have a role in creating the perceived status of groups of people by the very laws they create. Extreme examples of this can be found throughout history in laws created for segregation or voting rights for example. The PPACA does not acknowledge the importance of a mother taking time off from work to care for her newborn. On the contrary it has, in effect, declared that a woman can “do it all” - work while still breastfeeding her baby. The status of the new mother is not elevated to its rightful position. By offering her a room to express milk for her newborn, the government has placed employment at a higher level than motherhood. In addition to financial concerns, acceptance by her working peers and the rest of society could drive her to return to work earlier than desired.

When women do return to work postpartum many declare it as a negative experience. Mothers returning to work too soon after having a baby report feelings of remorse and stress. The first challenge mothers experience is identifying their role as both working employee and a nurturing mother. Often trying to balance time between these two roles leads to conflict where they feel guilty leaving their child behind in order to take care of work. Another challenge mother’s face is family stress. When a child is born, the mother’s relationship with her significant other diminishes rapidly as she tries to raise her child and dedicate time to work. Family and child care issues may also arise, when there is not enough family support to help raise the child, or there is no appropriate and affordable day-care center available. Financial issues further put a strain on the mother, as she weighs the pros and cons of staying home with the child and going to work to earn enough money to take care of the child. Lastly, psychosocial challenges present themselves when the mother feels absolutely drained from having no time for herself. Often the mother may feel depressed due to lack of sleep and neglecting personal needs (5).

The stronger these challenges interfere with the mother’s life, the harder it is for her to care for the family. The choices are often confusing and the mother may feel pressured to make uncomfortable decisions or decisions she may regret later. For example, putting a child in daycare is such a simple solution, yet the mother feels inadequate that she is not “motherly” enough to care for her own child. Society views breastfeeding as a motherly role to be filled by a mother. However, society often views working women in a more masculine type role and doesn’t associate working women with motherly instinct. Fulfilling the role of a mother and an employee is a constant conflict that no woman should have to be subject to. In the long run, parents of breastfed babies take less time off from work, since their child grows up healthier than bottle-fed infants. A labor statistic report revealed that caring for a sick child can lead up to a $360 financial loss per day if an employee is home taking care of a sick child. Stress from taking care of a sick child can cause a parent to transfer their stress onto others at work, or simply become absent-minded or distracted (9).
Criticism #2:

The PPACA also ignores the fact that there are physiological factors that drive mothers to breastfeed. Maslow’s Theory of Motivation (8) would show that the natural drive to nurture and feed one’s young must be realized in order for the mother to feel satisfied. When children suckle at the breast, the hormone, oxytocin is released, which stimulates feelings of relaxation and bondedness. Mothers expressing milk or pumping milk for later use are not creating a meaningful interaction with their child. A randomized placebo controlled human trial study tested oxytocin’s effect by injecting the hormone intranasally. As a result the subjects, injected with the active hormone showed increased trust and recognition of facial affects. They also showed a decrease in anxiety and decrease in fear related brain response patterns (10). The feelings of connection that oxytocin delivers are an essential aspect of breastfeeding. When oxytocin is released during these times it establishes a certain bond between mother and infant. Indeed, human mother’s milk is relatively diluted to increase contact with the child throughout the day (11). As a result, bottle feeding human milk will not give the mother the same association if the oxytocin is not released at the same time as feeding the baby. Also, as a mother spends more time at work, and less time producing oxytocin in the presence of her child, the further the feelings of separation may continue.

When these hormones are released in mothers, a maternal instinct kicks in, allowing the mother to perform instinctive behaviors of protecting her child. A mother who breastfeeds directly is more likely to watch over her child in dangerous situations, which further increases the chance of the child to survive. (6). Oxytocin also perpetuates maternal behavior so that the infant will not be neglected. One study in a hospital found a decrease in abandonment after delivery in association with breastfeeding (12). Another study revealed that breastfeeding less than 4 months is associated with maltreatment of the child, especially neglect. The lack of oxytocin released, which is meant to dampen the sympathetic nervous system “fight or flight” response, is believed to be the reason for the negative reaction (10).

The plan to create lactation rooms only deepens the divide between mother and child. Now mothers can return to work almost immediately, leaving their child to another caretaker. As women become more career focused, they may lose sight of special things, such as the innate connection developed with one’s child through breastfeeding. Furthermore, they are denying a basic physiological response to childbirth, which is breastfeeding, and the hormones that are released as a result of it.
Criticism #3

The PPACA also ignores the physiological needs of the infant. According to Maslow’s Hierarchy of Needs, the infant must feel safe in order to thrive. Infants have uninhibited reactions to the entire world around them, making them feel venerable. Stress related to the unpredictability of their world can be assuaged through human contact. The mother also feels a sense of satisfaction and connection when holding her child, which will further motivate her to breastfeed.

Physical touch provides nurturing to the child who, if deprived of this, is less likely to thrive (11). Back in the early nineteen hundreds, many parentless babies were put into large, clean facilities with ample food and nutrition. However, most of these babies did not live past seven months due to physical human neglect. Without human skin to skin contact, babies lose the motivation to eat and drink, fail to thrive and eventually starve to death. We now understand that human touch is an integral part of a baby’s ability to grow and develop. In hospital care units, such as the NICU, hospital volunteers and other staff members, massage the baby every 15 minutes or bring them out to hold them. In fact, the volunteers and staff that massage the babies regularly have lower anxiety, lower depression, and higher self esteem. They also drink less coffee and visit the doctor less frequently (7).

One study discovered that mothers who breastfed their babies tended to touch, cuddle, and smile more than mothers who used a bottle for feedings. Another study focused on the other reactions of sensory stimuli between mother and infant. At 3 days old, mothers who bottle fed were twice as likely to be gazing away from the infant than breastfeeding mothers. By the time the infant reaches 3 months old bottle feeding mothers were 8 times more likely to be gazing away from the infant. Tactile stimulation during feedings decreased from 3 days to 3 months in all the infants, however, breastfed infants still scored much higher throughout the study than bottle fed infants. Auditory stimulation for the infants increased from 3 days to 3 months, and the results were mixed (13).

Lactation rooms allow for mothers to be away from their child for much longer. There is no incentive or need for mothers to return home to breastfeed their child. A baby’s main mode of exploring their world is through skin contact, as their eyesight is very poor. As a result, they react to physical stimuli on their skin, which in turn will inform the infant whether or not they are in danger. Infants are not born fully developed, able to protect themselves. They rely on the physical safety they find in familiar skin to skin contact with their mother (7). The mother needs to be present, as the familiar touch and smells will soothe the child.

Intervention Strategy

In order to increase the rates of breastfeeding, the U.S. should create a policy intervention in which work organizations would be required to offer a maternity leave of up to 6 months with at least partial salary payment and job protection for all full-time employees. The goal is to motivate the new mother towards personal caretaking of her child. The motivation for the mothers will be based on the understanding that breastfeeding is a natural drive to feed one’s offspring. The time off from work will allow the new mother to adjust to the new role of motherhood. The drive to take care of her offspring will be focused on feeding and nurturing the child, instead of the concern about money for the family. As a result, the mother and infant will attain a higher level of satisfaction in Maslow’s Hierarchy of Needs (8). For the mother, she will attain self-esteem through breastfeeding and raising her child at home through a government mandated program which recognizes the importance of motherhood. The mother and infant will also attain the physiological needs that breastfeeding provides. The mother satisfies her drive to nurture her offspring, which is a basic instinct in all mammals. The infant satisfies his/her need through being fed by the mother. The human milk is the basic form of nourishment for the child, which is one aspect of what a child needs to grow. Lastly, the infant and mother will be motivated by the need of safety. The infant requires feelings of safety in order to grow, while the mother provides that role and helps protect her family. These are the more important factors that develop for a women who has just given birth. Striking evidence of the benefits of better maternity leave has been documented, while the use of lactation rooms has not (on a national-wide level).

In order for the mother to feel a higher sense of self-esteem and satisfaction, she will use the maternity leave as a chance to connect with her child and use her most basic drive, to raise offspring, to fulfill her self-worth. Several studies have shown that lengthened maternity leave promotes breastfeeding. Mothers report the need to return to their jobs as one of the top reasons to forgo breastfeeding in the long run (1). Several studies have shown that there is no significant difference in the initiation of breastfeeding between employed and non-employed mothers. However, employed women who planned to return to work within six weeks of giving birth were less likely to initiate breastfeeding. The compelling evidence arises when one views the relationship between duration of breastfeeding versus employed and non-employed mothers. One survey found that non-working mothers, on average, breastfed for 25.1 weeks compared to full-time working mothers who breastfed for only 16.1 weeks. Employed women were significantly less likely to be breastfeeding at three months compared to non-working mothers (9). The difference between initiation and duration of breastfeeding in working mothers proves that, although a mother may intend to breastfeed, there are few available resources to support the continuation of breastfeeding. If mothers could spend time away from work to take care of their child, while still maintaining a meaningful salary, then breastfeeding duration would increase in mothers who intend to breastfeed for longer.

A mother naturally deserves the right to care and breastfeed her child in a safe comfortable setting without distractions. The United States is almost the only developed country in the world that does not mandate paid maternity leave. In 2011 Australia will be the last developed country, besides the U.S., to have paid maternity leave policy. Currently under the Family and Medical Leave Act, enacted in 1993, employers must allow women three months of unpaid maternity leave with job security. Before this Act, maternity leave was actually under the Disabilities Act as a disabilities leave (14), which in itself is a misleading and derogatory label. Only 24 percent of the “top employers for working mothers” voluntarily provide paid leave for 4 or less weeks and over half voluntarily provide pay for 6 weeks or less (15). Six weeks does not fill the quota of the recommended 6 months of exclusive breastfeeding.

Canada has shown vast improvements in its maternity leave policies. When Canada extended their maternity leave with job security and compensation up to 12 months, new mothers waited to return to work for much longer. This expansion resulted in a 8.4% increase in mothers who exclusively breastfed for up to 6 months. Mothers were more likely to breastfeed for 1/3 of a month longer for each month they stayed home (16). One can see that Canada’s policy change undoubtedly assisted mothers in breastfeeding their infants. The example Canada has set for us should prove feasible in the United States if we were to implement a similar policy.

Research also shows that lengthened maternity leaves decreases stress and depressive symptoms in mothers. For each week maternity leave was lengthened, the mother reduced their depression by 6-7% rated on a depression scale (17). It has been reported that breastfeeding mothers, not bottle feeding mothers, showed overall decrease in anxiety and negative mood. The mothers reported less stress and their physiological function of stress response seemed to be diminished. A salient factor in this response is one of the primary hormones in breastfeeding: oxytocin. It appears that there are physiological hormones in place to allow mothers to cope with the stress of a new child. The physiological aspect of breastfeeding is an essential component in raising a child, and is concurrent with Maslow’s Hierarchy of Needs.

There is solid evidence that a comprehensive maternity is associated with a reduction in infant morbidity and mortality rate. Scandinavian countries have the longest and most comprehensive maternity leave compared to any other industrialized country, and also have the lowest infant and maternal mortality rates. Two studies have shown that longer maternity is associated with significant reduction in infant mortality and child mortality between the ages of 1-5 years old. The first study showed that each time the maternity leave is extended for another 10 weeks, the infant gains a 3-4% decrease chance in mortality. The next study showed, similarly that extending maternity leave by 10% decreases infant mortality by 3-5%. Furthermore, there is evidence showing that mother-child interactions can be affected by the length of maternity leave. In women attaining only 6 weeks of maternity leave, mother-infant interactions within four months of childbirth were significantly more negative than mothers who received 12 weeks of maternity leave (18). The importance of physical nurturing, mother to child, creates the sense of safety and security for both involved. One can see Maslow’s second level of motivation (safety needs) manifest as the mother becomes more and more attached and protective of her child.

The decision to ignore these drives or give in to these drives depends on the resources available, and what the mother views as the best possible outcome for her infant and for herself and family. The current PPACA does not go far enough in protecting the well being of mothers and their infants. If Maslow's theory is applied to the decisions involving the health of mothers and infants it becomes clear that a comprehensive maternity leave policy provides the best solution. The mother will have the safety of knowing she has an income and job protection, which will allow her to attain the need for self-esteem through breastfeeding. Maternity leave will also provide greater benefits to the infant than simply supplying human milk for physical sustenance. There is concrete evidence that proves that maternity leave is the best option for an employed mother to raise a child.

References

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3. Center For Disease Control and Prevention. Lactation Support Program. Web. Accessed April 26^th 2010. http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/lactation/

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11. Kluger, J. “Why We Love.” Time Magazine. January 19^th 2008.

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14.Equal Employment Opportunity Commission. Pregnancy Discrimination. Web. Accessed April 26^th 2010. http://www.eeoc.gov/laws/types/pregnancy.cfm

15. Lovell, V. et al. Maternity Leave in the United States. Institute for Women’s Policy Research. August 2007. IWPR #A131. Web. Accessed April 26^th 2010. http://www.iwpr.org/pdf/parentalleaveA131.pdf

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