Breast is Best?: Why the National Breastfeeding Campaign Falls Short in its Promotion of Breastfeeding

I. Introduction
Both the World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for an infant’s first 6 months of life and then continued breastfeeding with supplemental foods until at least 12 months (1, 2). However, in the United States, only 73.9% of women initiate breastfeeding, and only 43.4% of infants are still breastfed at 6 months of age (4). Even more startling is that only 13.6% are exclusively breastfeed to 6 months post partum (4). Furthermore, only 22.7% of mothers continue breastfeeding to 12 months post-partum (4). The government initiative “Healthy People 2010” strives to increase breastfeeding so that 75% of babies are breastfed early post partum, 50% are breastfed at 6 months post partum, and 25% at one year (3).
Breastfeeding has important implications on both maternal and infant health, making it an important public health issue. Breast milk contains antibodies, providing immune support and protecting infants from a wide range of infections (5, 6). Breast milk also coats and protects the infant’s digestive tract (5). Breast milk has been linked to lower rates of ear infections, respiratory infections, diarrhea, asthma, obesity, diabetes and SIDS in infants (5-10). In terms of maternal health, breastfeeding has been associated with a reduced risk of ovarian and breast cancers, a quicker return to pre-pregnancy weight, less postpartum bleeding, quicker involution of the uterus and delayed return of the menstrual cycle (5, 6, 11-15). Furthermore, breastfeeding promotes bonding between mother and infant and is cost saving compared to formula-feeding (5, 16).
The National Breastfeeding Campaign was initiated by the United States Department of Health and Human Services in an effort to promote breastfeeding to first-time parents (17). The Department of Health and Human Services worked with the Advertising Council to develop a media campaign that was launched in 2004 and lasted until 2006 (17). The campaign materials included three print ads which portrayed pictures of dandelions, ice cream scoops, or otoscopes, each of which looked similar to a pair of breasts (Figures 1-3). Each image then contained a statement saying “breastfeed for six months” followed by a brief corresponding message about breastfeeding being linked to a reduction in respiratory illnesses, obesity, or ear infections (17). This paper will address the shortcomings of this campaign and propose interventions that address those shortcomings.

II. Critique of the National Breastfeeding Print Ad Campaign
I contend that the print ads of the National Breastfeeding Campaign have three major flaws. First, this campaign is based on the Health Belief Model and does a poor job conveying disease susceptibility and severity. Second, this campaign does not recognize the importance of social networks and does nothing to change the social norms surrounding breastfeeding. And third, this campaign fails to address social or environmental issues that influence breastfeeding.

A. Poor Use of Model and Framing
The print ads of the National Breastfeeding Campaign convey one message: breastfeeding is a health benefit. As demonstrated by the Marketing Theory, a good marketing campaign is not based on the product, but rather what the intended consumer wants (18). The Marketing Theory maintains that good marketing campaigns will have two parts: a promise and support for the promise (18). For the campaign to be successful, the “promise” needs to be a core value. Health is not a core value and is not enough of a reason to incite behavior changes. Furthermore, using statistics as a support to the promise is weak and ineffective (18). Studies have shown that breastfeeding is not influenced by health care providers or health facts (19). Despite this, the National Breastfeeding Campaign used health to promote breastfeeding by using health as the core value in the Health Belief Model.
The Health Belief Model (HBM) is based on the framework that people make decisions about health behaviors after weighing the perceived benefits and barriers of those behaviors resulting in an intention of a behavior and then a behavior (20). According to the HBM, the perceived benefit of a behavior is influenced by perceived susceptibility and perceived severity to an outcome that the behavior is intending to prevent (20). In this case, the HBM suggests that when making a decision about breastfeeding women would weigh their perception of the benefits of breastfeeding against their perception of barriers to breastfeeding to reach a decision. Influencing their perception of benefit is the perception of susceptibility and severity of outcomes that would occur if they did not breastfeed. These ads do nothing to address the barriers associated with breastfeeding and, I believe, do a poor job at conveying susceptibility and severity. I contend that the ads are framed in a way that actually minimizes the susceptibility of illnesses.
The National Breastfeeding Campaign ads attempt to provide women with information on susceptibility and severity of respiratory infections, obesity, and ear infections that could arise from not breastfeeding. However, the ads, which are each similar to this one highlighting ear infections, read: “Breastfeed for Six Months. Help Reduce Your Child’s Risk for Ear Infections” (17). The message does not convey an infant’s susceptibility of ear infections regardless of their breastfeeding status and also does not convey the severity of ear infections (or respiratory illness or obesity). Furthermore, by framing it as a reduction of the potential poor health outcome, I think these ads make breastfeeding seem like “extra credit” or a “bonus.” In reality, breastfeeding is natural and healthy and should be viewed as the primary feeding option as opposed to being viewed as an added benefit. As demonstrated people have an aversion to loss (21). This ad campaigned is not framed as a “loss” but rather as a “gain.” The campaign promotes that the child will gain better health if breastfed and thus makes breastfeeding seem like a “bonus” because it is implying you can make your child healthier than the norm. This de-values the importance of breastfeeding.
Aside from the National Breastfeeding Campaign doing a poor job utilizing the HBM, I think that using the HBM itself was a poor model choice. The HBM is an individual level model and fails to account for other societal or environmental factors. It also assumes that “intention” influences behavior and that decisions are static (20). Studies have shown that breastfeeding is heavily influenced by outside factors and that an intention to breastfeed does not always result in breastfeeding (19). Factors influencing the decision to breastfeed are addressed in depth in section C.

B. Failure to Address Social Norms or Networks
Another failure of the print ads of the National Breastfeeding Campaign is that they do nothing to address the social norms surrounding breastfeeding. The ads also fail to incorporate the importance of social networks on breastfeeding. The National Breastfeeding Campaign is an individual level campaign intended to affect individual behaviors. However, it has been demonstrated that social support has a significant effect on breastfeeding (5, 6, 19, 22, 23). There are certain areas and cultures where breastfeeding is more accepted and more predominant it is more of a norm in those areas and cultures leading more women to breastfeed (4, 24, 25). As women become more acculturated in American society they become less likely to breastfeed (24, 25). This indicates that breastfeeding is not the social norm in the United States and that our current norm is negatively associated with breastfeeding.
Studies have shown that women that have support from their families are more likely initiate and continue breastfeeding (5, 6, 19, 22, 23). Similarly, women that have peer support are more likely to breastfeed and more likely to breastfeed for a longer duration (23). Furthermore, community support also has a positive effect on breastfeeding (19, 22, 23). Women often expect breastfeeding to be easy, when in reality it can be quite difficult. Without the proper support system in place, many women that had intended to breastfeed will give up (22). The Health and Human Services Blueprint for Action on Breastfeeding calls for a social marketing media campaign that portrays breastfeeding as the “normal” form of infant feeding (5).
The National Breastfeeding Campaign does not try to promote breastfeeding through any sort of social network or social norm. As mentioned in part A, I believe that the ads portray breastfeeding as a “bonus.” This attitude continues to reinforce that breastfeeding is not the social norm in the United States.

C. Failure to Address Social or Environmental Issues
I think that the predominant failure of the National Breastfeeding Campaign is its failure to address the social and environmental factors that influence breastfeeding. The decision to breastfeed is not solely based on knowledge that breastfeeding is beneficial and studies have shown that a wide range of factors beyond social norms and social networks affect breastfeeding (24-27). If these barriers are not addressed, the promotion and distribution of breastfeeding knowledge is essentially useless.
Studies have shown that lower levels of education and lower socio-economic status are related to lower rates of breastfeeding (24-27). Race is also a predictor of breastfeeding: African American are less likely to breastfeed than white women and Hispanic women are less likely to breastfeed than non-Hispanic women (23, 26). Age is another predictor of breastfeeding (24). As discussed in the previous section, family support, community support and role models play an important role in the initiation and continuation of breastfeeding (24-27).
Full-time employment has been linked to lower rates of initiation and continuation of breastfeeding (5, 6, 19, 22, 23). Studies have shown that women are unsure of how to balance employment and continued breastfeeding (27, 28). There are currently no national policies regarding breastfeeding or expressing milk and the workplace (5). Furthermore, if women feel that their employer does not support breastfeeding or feels that her career may be jeopardized by taking the time to do so, she will be less likely to breastfeed (5).
Common practices that are widely accepted also have negative impacts on breastfeeding. For example, it is a common practice for hospitals to distribute gift bags to new mothers that contain samples of infant formula. Studies have found that mothers that receive these samples are less likely to breastfeed than mothers that don’t (29-31). These samples can undermine a woman’s milk supply and inadvertently imply a hospital endorsement of formula feeding (31).
By failing to address these barriers to breastfeeding the National Breastfeeding Campaign ads are failing to address the main reasons that women do not breastfeed.

III. Proposed Intervention
My proposed intervention for the National Breastfeeding Campaign is an ecological model that addresses social norms and incorporates principles of the Marketing Theory.

A. Incorporation of the Principles of the Marketing Theory
The proposed intervention will use Marketing Theory to convey the ultimate goal of initiation and continuation of breastfeeding. Instead of using health as the outcome it will promote known core values in a two pronged approach. To convey the benefits to infants the proposed intervention will use core values of family, happiness, and “the American Dream.” It will also promote sex appeal to portray and “sell” maternal benefits. As demonstrated, health is generally not one of the most important values to people (18). The altered campaign will no longer use statistics and science as the support and will instead use images that convey the new core values. As shown, the majority of women already know the benefits of breastfeeding and these statistics on campaign ads do not influence decisions about breastfeeding (18).
The proposed intervention will also re-frame the issue so that breastfeeding is not viewed as “extra credit.” It is important to portray breastfeeding as natural and as the first choice (5)

B. Address Social Norms and Networks
The proposed intervention will work with local communities to create support groups and to increase awareness of breastfeeding. It will work to promote breastfeeding within communities and social networks and will also work to change the social norm. The use “opinion leaders,” or community members that will vocalize their support of breastfeeding, is an important way to encourage breastfeeding and to establish it as a social norm (32, 33). It is important to use a diverse group of opinion leaders so that many different women can identify with them (32).
The Diffusion of Innovations Theory maintains that if enough people adopt the new behavior a “tipping point” will be reached and that behavior will become the new norm (33). The “Be a Star Campaign,” a breastfeeding campaign in England, is an example of a campaign that is working to change social norms (34). It uses local mothers as examples and promotes the fact that they are breastfeeding. My proposed intervention will encourage local governments to begin programs consistent with this concept and will also work to change the social norms on a national level by exemplifying well know figures that breastfeed their children. Both the social norm theory and the theory of innovation maintain that as breastfeeding becomes the social norm, more women will initiate and maintain breastfeeding practices (32, 33).

C. Use of an Ecological Model
For this breastfeeding campaign to be successful, I think that it is extremely important to incorporate a multi-level intervention using an ecological model. Ecological models address many different levels of an issue including: intrapersonal, interpersonal, institutional, community and policy levels (35). If the major social and ecological factors that influence breastfeeding are not addressed it will be very difficult to accomplish higher rates of breastfeeding (27, 35). In my opinion, a woman can know all the facts about breastfeeding but without support and regulations that make it possible for her to breastfeed, she still might not be able to breastfeed even if it is her intention.
Starting at the broadest level, my proposed intervention will encourage governments and individual hospitals to institute policies promoting the idea of the “baby friendly hospitals” by banning the practice of infant formula distribution to new mothers by hospitals (36). The campaign will address the institutional level by encouraging businesses to develop policies and practices that support and promote working mothers that breastfeeding. In its “Blueprint for Action on Breastfeeding,” the Department of Health and Human Services has outlined many different ways that businesses can do this including the establishment of rooms designated for breastfeeding or expressing milk and refrigerators for storing breast milk (5).
The intervention will promote support at the community level as discussed in section B by working to change the social norms surrounding breastfeeding by utilizing social networks. The intervention will also work to encourage family support by targeting social networks. Studies have shown that if a woman’s family, and especially her partner, support breastfeeding she is much more likely to breastfeed. The proposed intervention will also work on the individual level, portraying widely held core values.
IV. Conclusion
Breastfeeding is a significant issue with critical public health implications both short term and long term. While the National Breastfeeding Campaign marketing ads might influence some individuals it is unlikely that it will have any population level effect. The failure of this campaign to social norms and networks along with its failure to address other social and environmental factors critically impairs it from having a meaningful effect. By incorporating a multi-level intervention that encompasses changes on the political, community, institutional (work place), interpersonal and intrapersonal levels, this campaign is much better suited to realize its goals of the promotion of breastfeeding.

REFERENCES
1. World Health Organization. Breastfeeding. Geneva, Switzerland: World Health Organization. http://www.who.int/topics/breastfeeding/en/.
2. American Academy of Pediatrics. APA Releases Revised Breastfeeding Recommendations. Elk Grove Village, IL: American Academy of Pediatricians. http://www.aap.org/advocacy/releases/feb05breastfeeding.htm.
3. Healthy People 2010. Healthy People Objectives. Wachington, DC: Department of Health and Human Services. http://www.healthypeople.gov/Document/HTML/volume2/16MICH.htm#_Toc494699660.
4. Center for Disease Control and Prevention. Breastfeeding. Atlanta, GA: Center for Disease Control and Prevention. http://www.cdc.gov/breastfeeding/data/report_card2.htm.
5. Department of Health and Human Services. Breastfeeding: HHS Blueprint on Action on Breastfeeding. Washington, DC: Department of Health and Human Services, 2000.
6. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115:496-506.
7. Scariati P, Grummer-Strawn L, Fein S. A Longitudinal Analysis of Infant Morbidity and the Extent of Breastfeeding in the United States. Pediatrics 1997;99:5-10.
8. Grummer-Strawn L, Mei Z. Does Breastfeeding Protect Agains Pediatric Overweight? Analysis of Longitudinal Data From the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics 2004;113:81-86.
9. McVea K, Turner P, Peppler D. The Role of Breastfeeding in Sudden Infant Death Syndrome. Journal of Human Lactation 2000;16:13-20.
10. Arifeen S, Black R, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive Breastfeeding Reduces Acute Respiratory Infection and Diarrhea Deaths Among Infants in Dhaka Slums. Pediatrics 2001;108:67-75.
11. Key T, Verkasalo P, Banks E. Epidemiology of Breast Cancer. The Lancet Oncology 2001;2:133-140.
12. Dewey KG, Heinig MJ, Nommsen LA. Maternal Weight-loss Patterns During Prolonged Lactation. American Journal of Clinical Nutrition 1993;58:162-166.
13. Weis HA, Potischman NA, Brinton LA, et al. Prenatal and Perinatal Risk Factors for Breast Cancer in Young Women. Epidemiology 1997;8:181-187.
14. Gwinn ML, Lee NC, Rhodes PH, Layde PM, Rubin GL. Pregnancy, Breastfeeding, and Oral Contraceptives and the Rick of Epithelial Ovarian Cancer. Journal of Clinical Epidemiology1990;43:559-568.
15. Chau S, Arulkumaran S, Lim I, Selmat N, Ratnam S. Influence of Breastfeeding and Nipple Stimulation on Postpartum Uterine Activity. Br J Obstet Gynecol 1994;101:804-805.
16. Virden SF. The Relationship Between Infant Feeding Method and Maternal Role Adjustment. Journal of Nurse-Midwifery 1988;33:31-35.
17. Department of Health and Human Services. National Breastfeeding Campaign. Washington, DC: Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/.
18. Siegel M, Lotenberg LD. Marketing public health:An opportunity for the health practitioner. In: Siegel M, Lotenberg LD, eds. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones & Bartlett, 2007.
19. Giugliani E, Caiaffa W, Vogelhut J, Witter F, Perman J. Effect of Breastfeeding Support from Different Sources on Mothers’ Decisions to Breastfeed. Journal of Human Lactation 1994;3”157-161.
20. Edberg M. Individual health behavior theories (pp. 129-143). In: Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett, 2007.
21. DeMartino B, Kumaran D, Seymour B, Dolan RJ. Frames, Biases, and Rational Decision making in the Human Brain. Science 2006;313:684-687.
22. Scott J, Binns C, Oddy W, Graham K. Predictors of Breastfeeding Duration: Evidence From a Cohort Study. Pediatrics 2006;117:646-655.
23. Arlotti J, Cottrell B, Lee S, Curtin J. Breastfeeding Among Low-Income Women With and Without Peer Support. Journal of Community Health Nursing 1998;15:163-178.
24. Celi A, Rich-Edwards J, Rishardson M, Kleinman K, Gillman M. Immigration, Race/Ethnicity, and Social Factors as Predictors of Breastfeeding Initiation. Archives of Pediatric & Adolescent Medicine 2005;159:255-260.
25. Singh G, Kogan M, Dee D. Nativity/Immigration Status, Race/Ethnicity, and the Socioeconomic Determinants of Breastfeeding Initiation and Duration in the United States, 2003. Pediatrics 2007;119:38-46.
26. Forste R, Weiss J, Lippincott E. The Decision to Breastfeed in the United States: Does Race Matter? Pediatrics 2001;108:291-296.
27. Tiedje L, Schiffman R, Omar M, Wright J, Buzzitta C, McCann A, Metzger S. An Ecological Approach to Breastfeeding. The American Journal of Maternal/Child Nursing2002;27:154-161.
28. Fein S, Roe B. The Effect of Work Status on Initiation and Duration of Breast-Feeding. American Journal of Public Health 1998;88:1042-1046.
29. Bergevin Y, Dougherty C, Kramer M. Do Infant Formula Samples Shorten the Duration of Breast-feeding? Lancet. 1983; 1:1148-1151.
30. Frank DA, Wirtz SJ, Sorenson JR, Heeren T. Commercial Discharge Packs and Breast-feeding Counseling: Effects on Infant Feeding Practices in a Randomized Trial. Pediatrics. 1987;8:845-854.
31. Rosenberg KD, Eastham H, Kasehagen LJ, Sandoval A. Marketing Infant Formula Through Hospitals: the Impact of Commercial Hospital Discharge Packs on Breastfeeding. American Journal of Public Health. 2008;98:290-95.
32. Valente T, Davis R. Accelerating the Diffusion of Innovations Using Opinion Leaders. The ANNALS od the American Academy of Political and Social Science 1999;566:55-67.
33. Oldenburg B, Hardcastle DM, Kok G. Diffusion of innovations. In: Galnz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass;1997:270-286.
34. Be a Star. Breastfeed: Be a Star. England: Be a Star. http://www.beastar.org.uk/.
35. McLeroy K, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 1988;15:351-377.
36. Baby Friendly USA. Baby Friendly Hospital Initiative in the US. Sandwich, MA: Baby Friendly USA. http://www.babyfriendlyusa.org/eng/index.html.