Monday, December 18, 2006

"Babies Were Born To Be Breastfed": Public Health Campaigns Are Born To Fail When Mothers Are Blamed – SzePui Cheng

Current public health policy in the United States places expectations on mothers to breastfeed regardless of social and environmental barriers, including lack of support in the workplace. Given the known health benefits of breastfeeding, mothers who do not breastfeed are characterized as making the choice to deprive their children of these benefits. In fact, recent breastfeeding promotion efforts by the U.S. Dept. of Health and Human Services (HHS) targeted mothers who already face obstacles in breastfeeding decision-making.

HHS’ “Babies Were Born To Be Breastfed” campaign emphasized risky behaviors, and sent the message that individuals are solely responsible for their health choices and essentially can be blamed for taking health risks. However, blaming mothers for taking the “risk” of not breastfeeding did not provide any incentive for employers and society in general to make appropriate accommodations that would have allowed all mothers to have a genuine choice about breastfeeding in the first place.

If public health policymakers do not account for societal factors related to breastfeeding behavior and continue to blame mothers for making the “choice” to not breastfeed, then they will continue to fail to achieve optimal rates of breastfeeding in the U.S. In addition, policymakers will continue to perpetuate breastfeeding disparities among certain racial and socioeconomic groups – the same groups that already experience disparities in various education and health services.

History of Breastfeeding in the United States

In the late 19th century, breastfeeding habits in the U.S. began to change due to economic factors for working-class mothers, who switched to “hand-feeding” in order to leave their homes for employment. Evolving social norms also induced middle class women to stop breastfeeding so they could be better “companions” for their husbands. (15) Despite several public health efforts in the early 20th century, the breastfeeding initiation rate steadily declined to an all-time low of 24% in 1971. (15) The subsequent feminist and women’s health movements helped revive interest in breastfeeding practices.

Today there is a wealth of literature that documents the nutritional, immunological, developmental and psychological benefits to infants who are breastfed. Children who are breastfed have lower rates of ear infections, diarrhea, respiratory illnesses, and childhood obesity. Also, there is some evidence that mothers who breastfeed enjoy certain protective health benefits such as reduced risks for breast and ovarian cancers. (2)

In order to maximize these benefits, the American Academy of Pediatrics recommends breastfeeding for the first year of a child’s life, preferably with exclusive breastfeeding for the first six months. (9) Initiation of breastfeeding is often accomplished while the mother and child are still in the hospital setting; however, there is evidence that the duration of breastfeeding has a higher correlation to health benefits. That is, there is a “dose-response relationship” between breast milk and child health. (15)

Currently, breastfeeding is initiated with approximately 70% of all American children, which is a substantial increase from previous decades. (9) However, given the overwhelming evidence that breastfeeding is the optimal form of nutrition for infants, we must examine the reasons why the United States still lags behind other developed nations in rates of breastfeeding. Countries such as Germany, Australia, and Norway have breastfeeding initiation rates of 86%, 87% and 99%, respectively. (5)

In addition, only 17% of all American children are breastfed exclusively at 6 months of age (15), compared to 50% of children in Norway. A large portion of this gap can be attributed to the disparity in rates between certain racial and socioeconomic groups in the U.S. Research has shown that mothers who are black, single, less than 20 yrs, and/or living below the poverty level in the U.S. have substantially lower rates of breastfeeding initiation and continuation. The 2004 National Immunization Survey found that although rates of breastfeeding had increased from 1994 (initiation: 60.3% to 71.5% for white children, 25.5% to 50.1% for black children; continuation of those breastfed to 6 months: 44.4% to 53.9% for white children, 33.3% to 43.2% for black children), there was no significant reduction in the absolute racial disparity. (3) Also, among all racial groups, rates of breastfeeding among lower income groups were approximately 25% less than higher income groups. (3) To increase rates of breastfeeding among these groups, policymakers currently advocate “targeting” these subgroups that are least likely to breastfeed. (3)

Current Efforts

At the national level, agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration work to support breastfeeding through various strategies such as program evaluation, applied research and regulation of breast pump manufacturers. HHS has attempted to promote breastfeeding through its Blueprint for Action on Breastfeeding, which included recommendations for steps to be taken by health care providers, employers, and families and communities, as well as identification of areas of research. (2)

In 2002, HHS commissioned the Ad Council to create a social marketing campaign, ultimately entitled “Babies Were Born To Be Breastfed”. (2) This series of advertisements appealed to the “common sense” of mothers, stating that since women avoided risky behaviors during pregnancy, it made sense that they would avoid risky behaviors with their infant children. In one television commercial, a “pregnant” woman rode a mechanical bull inside of a bar, while a rowdy audience cheered her on until she was thrown to the ground. The message equated the risks of this behavior with the risks of not breastfeeding, i.e. since a woman can make the choice of whether or not to get on the mechanical bull, she can make the choice of whether or not to breastfeed.

There was a great deal of controversy surrounding this campaign, and its focus on risky behaviors was deemed “scare tactics” by some critics. (13) While it can be argued that individuals must be responsible for making decisions about their own health and those of their dependents, it must be acknowledged that those choices are limited to the set of options that exist in the context of their individual lives. For example, a college-educated, middle class mother is making her choice to breastfeed on a very different contextual basis than a mother with less than a high school education, living below poverty level. The latter often have a less-educated social support network and little choice in employment options, and therefore, little or no negotiating power with their employers. By claiming that all mothers have the same choices, there was clearly a message of blame towards mothers who do not breastfeed embedded in the “Babies Were Born To Be Breastfed” campaign.

The campaign also only addressed individual-level causes of lack of breastfeeding. Practitioners who subscribe to the theory of the Health-Belief Model (10) assume that mothers, once educated about the benefits of breastfeeding and risks of not breastfeeding, will make the rational nutritional choice for their infants. If policymakers wish to assume that mothers make decisions about breastfeeding based upon a risk-benefit analysis, they must consider how to classify risk.

In a discussion about public health education and lifestyle risk, Lupton describes the distinction made by the public health community between risks related to external causes out of the individual’s control and those risks caused by oneself. (6) If there is a moral distinction between these two categories of risk, then an individual can be blamed for taking health risks. Certain poor health outcomes are considered to be self-inflicted.

Proponents of the “Babies Were Born To Be Breastfed” campaign believed that by educating certain mothers about the risk, a moral obligation to breastfeed would arise among those groups. They claimed that mothers should make the responsible choice to eliminate the risks to their children and themselves. Again, by implying that all mothers can make the same choice to avoid risk, there was clearly a message of blame directed towards non-breastfeeding mothers.

The less-than-impressive rates of breastfeeding in the U.S. compared to other nations, as well as the continued disparities among different racial and socioeconomic groups demonstrate that this strategy of blame is not effective. In order to create a successful public health campaign aimed at reducing these disparities, significant societal-level barriers to breastfeeding behavior need to be addressed.

Barriers to Breastfeeding

Social Factors

There are cultural norms within the United States, and its many complex subpopulations, that cause mothers to feel uncomfortable breastfeeding. Mothers who attempt to breastfeed in public areas often face prejudice and discrimination. (4) In addition, most social environments are structured in a way that makes breastfeeding burdensome and inconvenient compared to bottle-feeding.

Federal legislation for breastfeeding policies has been proposed over the years, with little action taken by Congress. Programs and guidelines have been suggested to protect the rights of mothers to breastfeed; however, there has been no movement towards implementation. In fact, the only laws that have been enacted to promote breastfeeding have been by individual states, and pertain only to “permitting” mothers to breastfeed in public and exempting them from charges of indecent exposure. (14) Other laws are primarily symbolic, with no enforcement or realistic guidelines for implementation. (4) The unfortunate state of breastfeeding laws in the United States highlights the cultural norms that dictate priorities for federal programs.

The implied message of current public health policy is that breastfeeding behavior is an individual choice and responsibility, and that interventions should be structured to provide education about the risks of not breastfeeding. As a result of this approach, some of the main barriers to breastfeeding in the U.S. are the attitudes, practices, and lack of knowledge of those who could be the strongest advocates for breastfeeding mothers.

The Healthcare Environment

It should not be unreasonable to expect healthcare providers to provide education and access to support services for mothers considering breastfeeding. Most mothers in the U.S. are dependent upon physicians for peri-natal advice. Unfortunately, there is research that indicates that pediatricians and other physicians are insufficiently educated in this area. (8;11) A survey by the American Academy of Pediatrics found that only 65% of the respondent pediatricians recommended breastfeeding for the first month after birth, clearly indicating that their practices were not aligned with national policy recommendations. The majority of the respondent physicians also stated that they had not recently received, but wanted more breastfeeding management education. (11) In addition, 72% of these pediatricians were unaware of massive worldwide efforts to increase breastfeeding, including the UNICEF Baby Friendly Hospital Initiative. (11) If physicians were unaware of the priority that the global health community has placed upon breastfeeding promotion, it can be assumed that they could not relay that information to their patients.

Furthermore, according to a national assessment of physicians’ breastfeeding attitudes, the best predictor of a physician’s ability and willingness to give breastfeeding advice and support is whether that physician or the physician’s spouse has ever breastfed. (15) This could have significant consequences for mothers who rely upon physicians’ recommendations for infant nutrition. Also, there is evidence that a physician’s perceptions of a patient’s likelihood of having adequate social support, and likelihood of adhering to treatment, will predict his/her recommendations to that patient. (12) Given the influence of these perceptions, along with policymakers’ push to target certain socioeconomic and racial groups (3), we must consider the implications this has for recommendations to mothers that have been labeled as least likely to breastfeed. It is possible that some physicians do not recommend breastfeeding to certain groups of women because they believe that these women will not be successful in breastfeeding. This may significantly reduce the range of “choices” available to these women.

If healthcare providers are to be considered the public’s gatekeepers to health knowledge (12), they must be able to offer appropriate information and support to mothers of all circumstances. Physicians who lend their professional knowledge to the debate surrounding breastfeeding behaviors can help to dispel the blame placed by campaigns such as “Babies Were Born To Be Breastfed”. If healthcare providers do not make recommendations that consider social and environmental barriers, they are contributing to disparities in vital health services.

Employment Settings

Another major factor that affects mothers’ decisions to breastfeed is their work environment. A study in Austin, Texas showed that although employers understood the benefits of breastfeeding for mothers and children, they were not eager to institute breastfeeding policies at their companies. Factors they cited as concerns included the cost of creating lactation facilities, reduced employee productivity, lack of employee demand, and liability issues. (1) Some employers felt it was adequate to accommodate employees on an “as-needed basis”. In addition, mothers have expressed their reluctance to breastfeed because they were concerned that their coworkers would be disgusted, intolerant, or disapproving. (1) The “Babies Were Born To Be Breastfed” campaign did not even acknowledge these physical and social barriers.

At this time, there are inconsistencies in breastfeeding accommodations in various work environments. Although some large corporations have lactation facilities, most of them fail to make appropriate accommodations for all levels of workers. Mothers with high-wage jobs often have private offices or special nursing rooms, whereas mothers with low-wage jobs are not given sufficient privacy and break times. This disparity has been called a “2-Class System” whereby those who are already advantaged continue to receive privileges, while those who are disadvantaged continue to suffer hardships. (4)

In the U.S., more than half of all women with children less than a year old work outside the home. Due to obstacles in the workplace, women who work full-time tend to wean their children earlier. (1;15) Currently the U.S. government only mandates that employers provide 12 weeks of unpaid leave for expectant mothers and fathers. (14) Short-term maternity leaves can often deter mothers from breastfeeding initiation, and more importantly, reduce their duration of breastfeeding. Again, women who are more financially secure have more options to choose from, such as longer unpaid maternity/lactation leaves.

Although many women are not provided with accommodations to pump breast milk at work, the “Babies Were Born To Be Breastfed” campaign implied that mothers should choose to breastfeed regardless of these external constraints. In fact, mothers were encouraged to notify employers of their intent to breastfeed and request that their employers provide appropriate accommodations. (2) If recommendations by HHS were insufficient to convince employers to accommodate breastfeeding practices, then surely individual requests by female employees would be even less persuasive. By implying that all employees have the same power to negotiate with their employers, policymakers again placed the responsibility of breastfeeding decision-making onto mothers without looking at environmental barriers.

The lack of uniform corporate lactation programs in the U.S. should be viewed as a form of workplace discrimination - forcing some mothers to “choose” between earning a living or breastfeeding. The public health community must address employers’ contributions to the disparities in supportive environments for breastfeeding mothers.

Supporting Mothers

The designers of the “Babies Were Born To Be Breastfed” campaign failed to recognize that health behaviors are influenced by many factors such as the external environment, cultural norms, beliefs, and attitudes about self-efficacy, that is, one’s own ability to perform the behavior. (6) As discussed earlier, healthcare providers can also be influenced by their perceptions of populations grouped by race and socioeconomic factors. Mothers who are black, single, young, and/or living below the poverty level may not be expected nor encouraged to breastfeed. In addition, these mothers may not feel a sense of self-efficacy, based on their physicians’ recommendations, as well as social and financial circumstances.

Individuals cannot make choices based solely upon an analysis of the risk of one behavior. When considering breastfeeding, mothers must analyze the constraints of their environment. The context within which choices are made is a significant part of the decision-making process. Without proper support from healthcare providers, employers, policymakers and society in general, mothers of all backgrounds cannot be expected to make rational choices about breastfeeding.

Public health campaigns that continue to blame individuals, such as disadvantaged mothers who do not breastfeed, for “risky” health behaviors will not only alienate the individuals who need the most assistance, but suppress public support for equitable health programs. As a result, racial and socioeconomic disparities will be perpetuated by the same policies that aim to reduce them.

Conclusions

There is a danger that the public health community believes that current breastfeeding promotion efforts are effective. Rates of breastfeeding initiation are increasing, especially among “targeted” mothers. However, rates of breastfeeding duration are quite low, particularly among the same “targeted” mothers, and there has been no reduction in the disparities among racial and socioeconomic groups.

The creators of social marketing campaigns such as “Babies Were Born To Be Breastfed” must learn from their mistakes, and begin to target the correct audiences by first educating healthcare providers, providing incentives for employers, and understanding cultural norms. HHS is getting ready to launch a campaign called “The Business Case for Breastfeeding” which is intended to inform employers about the financial benefits for providing breastfeeding accommodations such as reduced absenteeism and medical bills. (4) Hopefully, this will be a step in the right direction.

Finally, in order to achieve optimal rates of breastfeeding, public health policymakers need to focus on efforts that acknowledge the difficulties that women face in breastfeeding decision-making, and work to reduce and eliminate social and environmental barriers for all mothers who choose to breastfeed.

Sources

1. Brown, C.A., Poag, S., Kasprzycki, C. (2001). Exploring Large Employers’ and Small Employers’ Knowledge, Attitudes, and Practices on Breastfeeding Support in the Workplace. Journal of Human Lactation, 17(1), 39-46.
2. Department of Health and Human Services. (2000). HHS Blueprint for Action on Breastfeeding.
3. Center for Disease Control. (2006, March 31). Racial and Socioeconomic Disparities in Breastfeeding – United States, 2004. Morbidity and Mortality Weekly Report, 55(12), 335-9).
4. Kantor, J. (2006, September 1). On the Job, Nursing Mothers Find a 2-Class System. The New York Times.
5. La Leche League International. (2003). LLLI Center for Breastfeeding Information: Breastfeeding Statistics, Sept. 15, 2003. Retrieved Dec. 1, 2006:
http://www.lalecheleague.org/cbi/bfstats03.html
6. Lupton, D. (1993). Risk as Moral Danger: The Social and Political Functions of Risk Discourse in Public Health. International Journal of Health Services, 23(3), 425-35.
7. National Women’s Health Information Center. (2004). National Breastfeeding Campaign (Ad Council materials). Retrieved October 5, 2006: http://www.4woman.gov/breastfeeding
8. Phillip, B. (2001). Physicians and Breastfeeding Promotion in the United States: A Call for Action. Pediatrics, 584-8.
9. Porter, D. (2003). Breastfeeding: Impact on Health, Employment and Society. CRS Report for Congress, The Library of Congress.
10. Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs, 2, 328-35.
11. Schanler, R., O’Connor, K., and Lawrence, R. (1999). Pediatricians’ Practices and Attitudes Regarding Breastfeeding Promotion. Pediatrics, 103(3).
12. van Ryn, M, and Fu, S. (2003). Paved With Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health? American Journal of Public Health, 93(2), 248-53.
13. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved October 5, 2006 from ABC News: http://abcnews.go.com/2020/story?id=2188066.
14. Weimer, D. (2003). Summary of State Breastfeeding Laws. CRS Report for Congress, The Library of Congress.
15. Wolf, J. (2003). Low Breastfeeding Rates and Public Health in the United States. American Journal of Public Health, 93(12), 2000-10.

12 Comments:

Blogger Michael Siegel said...

I think you highlight some important social and environmental factors that are largely contributing to lower than desired rates of breastfeeding. But more importantly, you provide a compelling argument that current campaigns, which focus on making women feel guilty about not breastfeeding, may be counterproductive because they fail to address the underlying structural and contextual factors and end up undermining the idea of personal decision-making, plus they make a lot of women feel guilty unnecessarily. I think that the Health and Human Services Department could benefit from your commentary.

11:01 AM  
Anonymous Anonymous said...

I really enjoyed reading your essay! I had no idea that there was US legislation regarding breast feeding, and I was blown away that such a small percentage of pediatricians were aware of the current politics. Thanks for informing me!
-Heidi

9:09 AM  
Anonymous Stephanie said...

Awesome paper! It is well written and very well supported.

I found your comment on the “2-Class System” (women who are already advantaged continue to receive privileges, while women who are disadvantaged continue to suffer hardships) quite interesting. It just goes to show how powerful a role SES plays in one's lifestyle, especially in one's health. It brings to mind the saying "the rich get richer, the poor get poorer," which can certainly be applied to economic wealth as well as the wealth of health and a supportive environment. I think one of the major reasons european countries have a significantly higher rate of breastfeeding is that their employees provide them with one year PAID (yes, you heard right, ladies, PAID) maternity leave. If the US government mandated a similar law, at the very least to allow for 6 months of paid vacation time, I am sure more mothers would be breastfeeding.

Again, excellent paper. Your hard work paid off!

1:38 PM  
Anonymous Anonymous said...

This well written and extensively documented treatise clearly indicts are health system and government for not doing more for the health of ourhealth critiques by this author whom the Secretary of Health and Human Services would be well served to emulate.

Lawrence Eron MD FACP

12:31 PM  
Anonymous Anonymous said...

Proof-read version:
This well written and extensively documented treatise clearly indicts our health system and government for not doing more for the health of our citizens. I look forward to further health critiques by this author whom the Secretary of Health and Human Services would be well served to emulate.

12:34 PM  
Anonymous Anonymous said...

I wonder how anyone can write a paper about breastfeeding and the strugle some women face when they do not have any experience on the actual subject on hand, nor do they have no experience with children.

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