Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

An Evaluation of the Implementation of the Department of Health & Human Services’ Breast Feeding Campaign’s Lack of Effectiveness—Victoria María Klyce

It is well documented that babies who are breastfed have lower morbidity and mortality rates than babies who are bottle-fed (1). The protective properties of breastfeeding are well understood. Breast milk contains a wide range of many biologically active compounds including cytokines, hormones, and enzymes that function in the maturation of a child’s immune system (1, 2, 3). Breast milk also transfers immediate protection against microbes from mother to child through the specific immune response via activation of antibodies and the non-specific immune response via activation of proteins, glycoproteins, and lipids. In an effort to increase breast feeding rates among women, in June 2004 the United States Department of Health and Human Services (DHHS) launched a nationwide campaign to increase exclusive breastfeeding for at least 6 months to 50% (4). The need for a breastfeeding promotion campaign is clear. In 1995, 59.7% of mothers initialized breastfeeding, and only 21.6% of mothers were breastfeeding at 6 months (5). In a randomized experimental study published in the Journal of Nutrition, babies in the exclusive breastfeeding group crawled sooner and were more likely to be walking at 12 months than infants in the group where formula supplemented breastfeeding (6). The DHHS website lists many benefits to breastfeeding, including easier digestion for the baby, and the baby being at lower risk of SIDS (in the first year of life), and Diabetes type I and type II, lymphoma, leukemia, Hodgkin’s disease, overweight and obesity, high cholesterol and asthma (4). Studies have also shown that breastfeeding helps the mother lose the weight gained during pregnancy (4, 6), as well as lowering the mother’s risk for ovarian and breast cancer, and lessening postpartum uterine bleeding (4). The DHHS Breastfeeding campaign used radio, video, and print to with the goal of increasing the percent of mothers exclusively breastfeeding for six months. However, due to incorrect source, audience, message, and destination of the intervention this campaign was not successful.

DHHS National Breastfeeding Campaign
The DHHS Breastfeeding campaign includes two video commercials, two radio spots, and four print ads. The video ads show women doing reckless behavior while pregnant, both finishing with the statement: “You wouldn’t take risks before your baby is born, why start after?” Both radio commercials are narrated by men telling women to breastfeed exclusively for six months. The print ads show images of dandelions, ice cream scoops, and otoscopes simulating breasts, and the bold words “Babies were born to be breastfed”. The three print ads with images state in small letters: “Breastfeed for six months. Help reduce your child’s risk for _______”, with varying ailments which correspond to the picture (i.e. obesity with ice cream) (4).

The DHHS campaign to promote exclusive breastfeeding has not been successful. Firstly, the campaign’s focus is inappropriate, having “Babies were born to be breasted” as the take-away tag line is not constructive to promote exclusive breastfeeding for six months. Secondly, it applies only the Health Belief model and Social Cognitive Theory, assuming that the only barriers to mothers breastfeeding are that they are ignorant of the severity and susceptibility their child will have for disease if they do not breastfeed, and that they lack self-efficacy, which is promoted through guilt. Both these assumptions are incorrect. Lastly, the campaign lacks an effective frame. The campaign needs to employ social science and alternative modeling methods in order to be effective, including Social Market Theory, Framing Theory, Social Expectations Theory, Advertising Theory, and Stigma Theory.

Initialization of Breastfeeding is Not the Right Message
The DHHS Breastfeeding intervention’s message of demanding women to initialize breastfeeding is misguided. Seventy-four percent of mothers breastfeed their babies immediately after birth, while only 30% are breastfeeding at three months and 22.3% are breastfeeding at six months (7). The fact that 26% of mothers do not initiate breastfeeding could be for a variety of reasons, such as maternal infection with HIV/AIDS, adoption, inability to produce milk, or baby allergy. Therefore, an intervention aimed at achieving that these 74% of mothers who initiate breastfeeding continue to do so exclusively for six months will have the more significant benefit to society. Furthermore, the DHHS study’s self-identified goal is not to increase initiation of breastfeeding to 100%, but to increase exclusive breastfeeding for six months to 50% (4). An effective campaign requires a proper message, and the DHHS campaign to promote exclusive breastfeeding for six months does not provide one. The take away catch phrase—babies were born to be breastfed—promotes breastfeeding initiation, not exclusive breastfeeding for six months. The facts are clear on that there is not a great need for a campaign to increase the initiation of breastfeeding.

The campaign needs to focus instead on who is not continuing to breastfeed and why. There is great variation in breastfeeding rates amongst sociodemographic characteristics. Only 19.8% of African American infants were breastfed for three months, compared to the national average of 30%. Young mothers breastfed for three months at a rate of 16.8%, and mothers with a high school education (22.9%) or less (23.9%) were also far less likely to breastfeed for three months. Only 18.8% of unmarried mothers who initiated breastfeeding continued to do so at three months, and rural mothers and mothers who were poor each had breastfeeding rates of 23.9% (7). These mothers chose to initiate breastfeeding, so one can infer that they see the value in breastfeeding but met an obstacle that disallowed them from continuing.

The DHHS campaign, which aims to persuade these women to continue to breastfeed through its media campaign, will not only fail to achieve this goal, but could have additional harmful effects. Stigma Theory tells us that an individual will live up to a label placed on him or her, or the primary group he or she identifies with (8). In this case, a woman who chose to initiate breastfeeding but was unable to continue will see the DHHS ads equating not exclusively breastfeeding for six months with risky, reckless behavior and be labeled as a “bad mom”. This will have two major consequences. The first is that she will think of herself as a bad mom, and Stigma Theory tells us she will be more likely to live up to that label. Secondly, she will feel judged by the public health campaign, and this will foster distrust and animosity toward health campaigns in general. This mother will now be harder to reach regarding childhood immunizations, cigarette smoking, fruit and vegetable consumption, et cetera.

Instead of stigmatizing mothers who do not continue to breastfeed with the current implementation, DHHS should instead widen their view of why half of mothers begin to breastfeed and stop before six months. The current campaign applies only the Health Belief Model and Social Cognitive Theory, assuming that the only barriers that impede a mother breastfeeding for six months are that she is unaware of the risks of not doing so and that she lacks the necessary self-efficacy to achieve it. These models are not appropriate to be the primary tools implemented in this intervention because there exist other more fundamental causes for the low rates of breastfeeding, which should be addressed with Social Expectation Theory.

Social Norms and Legislation are Barriers to Breastfeeding
Currently 21 states have laws decriminalizing breastfeeding—which leaves 29 states where breastfeeding is considered a lewd act (9). The barrier is thus not lack of assertiveness or ignorance on the mother’s part, but the social norms, values, and expectations of society, which are reflected and reinforced by the legislature, or lack or legislature. Most states do not require employers to allow mothers to breastfeed or pump while at work. Even those that do have exceptions, such as “if it is busy in the office” (10). These issues are of special importance to mothers who are poor and cannot take time off, single working mothers, and mothers with less education who work in hourly paid jobs.

States that do not count breastfeeding as a lewd act still do not create a culture accepting of breastfeeding. Missouri, for example, states that mothers must breastfeed "with as much discretion as possible". Thus, the language frames breastfeed as a necessary evil, a shameful procedure that should be minimized. Furthermore, the ambiguity of the language gives individuals the power to approach a breastfeeding mother and accuse her of not being discrete enough, and thus committing a lewd act (9).

In states where laws exist protecting breastfeeding they are not always honored. There have been high profile cases in many states where mothers were told to leave public and private establishments where they legally had the right to breastfeed (10). In the last month alone there have been many instances in the news of discrimination against breastfeeding mothers. In Vermont a woman, her husband, and their baby were removed from a plane when the mother declined the flight attendants demand that she cover her baby’s head with a blanket while breastfeeding. After waiting on the plane for nearly three hours due to delay, she had begun to breastfeed her daughter, sitting at her window seat, with her husband sitting beside her. She told the flight attendant that she was exercising her right to breastfeed her child, but was still forced off the plane in tears (11, 12). A woman in Maryland was sentenced to a night in jail and a $150 fine when she asked to postpone jury duty in order to breastfeed her 12 week old baby (13). In Texas a mother was kicked out of a hair salon in the middle of her haircut because she attempted to breastfeed her infant (14). Clearly, without changing the public’s attitude toward breastfeeding the rates of breastfeeding cannot increase.

The DHHS campaign does attempt to use Agenda Setting Theory to create awareness of the necessity of breastfeeding, however, store owners who ask a mother to breastfeed in the bathroom, or legislators who demand breastfeeding be “discreet” do not need more information on the list of diseases that breastfeeding can avert. What they need is a change in the culture of the United States. They need to be more comfortable with the image and presence of a breastfeeding mother. Posters with dandelions about asthma will not make a restaurant owner allow a woman to breastfeed in his store. He needs to fell assured that a woman breastfeeding will not disturb or offend the other patrons. He needs to consider it “socially acceptable”. The DHHS breastfeeding campaign does nothing to achieve this.
Lack of Imagery of Mothers, Babies, and Breastfeeding
The frame that the DHHS attempts to employ is not continuous across media types, with the exception that each includes the catch-phrase: Babies were born to be breastfed. The video frame is that not breastfeeding is reckless and irresponsible; and not doing so means a mother is knowingly and willingly disregarding her baby’s well being, The radio commercials both attempt to be creative through comic music spoofs, but both consist of the leading man telling the female back-up singers that if they don’t breastfeed they are bad mothers. The print ads list diseases that a baby who is not breastfed for six months is at higher risk for. Not one of these ads in any of the three medias portrays a mother breastfeeding. The radio commercial is not a woman talking about the joy of breastfeeding and how happy she is to do it. Not one of the two forms of visual media shows an image of a mother breastfeeding: in fact, none of them show babies at all. An effective frame should go for the heart, not discuss rational decision-making.

An appropriate frame should portray a mother breastfeeding as a beautiful, harmonious image. These images should be both displayed on billboards around town in print ads and shown in the video commercials. This would create a unifying feeling throughout the campaign and improve the public’s image and comfort with breastfeeding. When people see a mother breastfeeding in a café they will not associate the exposed breast with a lewd act, but with the warm feeling they experienced when they saw the breastfeeding campaign ad. Likewise, a woman who is breastfeeding will not feel awkward and apologetic, she will feel beautiful and the center of the world, like the women in the breastfeeding ads. Especially in a nationwide intervention targeting a diverse population on many levels, the DHHS should think carefully about what the takeaway message of the campaign will be. According to ABC news, America’s very low breastfeeding rate (the lowest of any industrialized country) could be due to Americans’ discomfort with the image of a breastfeeding woman (15)
The DHHS breastfeeding intervention is thus inappropriate because it fails at a number of points. McGuire’s Communication Persuasion Matrix lists the five pieces necessary in changing behavior: source, audience, channel, message, and destination (16). When we apply this matrix to the DHHS Breastfeeding campaign we can quickly see that the campaign’s failures are comprehensive. The source of the message is an omnipresent voiceover in the videos, a critical man in the radio commercials, and an unclear government entity in the print ads. As for the audience, the ads are directed at mothers and future mothers: “You wouldn’t take risks before your baby is born, why start after?” This targeting of mothers places all the burden of breastfeeding on the mother. The intervention attempts to use guilt to persuade mothers to breastfeed in the current climate and social norms (which are not accepting of breastfeeding) instead of targeting society as a whole. In order to increase rates of breastfeeding the DHHS would need to properly determine what the barriers are to breastfeeding and address those barriers. The channel—video commercials, radio commercials, and print ads—is appropriate because they reach mass audiences. The message is flawed in more than one way. The tag line, “Babies were born to be breastfed” is offensive in its judgment—it implies that if a woman is unable to breastfeed her child she is failing to provide her baby with a basic and essential human right. The tag line is also inefficient due to incorrect focus on initialization of breastfeeding. The second part of the DHHS message, that your baby will be at high risk for obesity, asthma, diarrhea, SIDS, and infectious disease if not breastfed, simply ads more guilt and stress to mothers who are already anxious due to lack of protective legislature and social norms supporting a breastfeeding mother. Lastly, the problem with the destination—the intervention’s intended and desired result—is tied closely to the problem with the target audience. The intervention’s destination is for mothers to choose to breastfeed. However, in a country with social and legislative barriers, like those present in the United States, this destination is not appropriate.

The need for an intervention to promote breastfeeding for six months nationwide is apparent due to the low rates of breastfeeding and the benefits of breastfeeding to baby, mother, and society. However, the Department of Health and Human Services’ breastfeeding campaign is not the needed intervention. The study achieved an increase in the public’s perception of the susceptibility of babies who are not breastfed to disease and the severity of that disease. However, after one year of the intervention, fewer women felt “very comfortable” breastfeeding their own baby in public, and fewer women felt “very comfortable” seeing another woman breastfeed her baby in public (17). Thus, more people see not breastfeeding as dangerous, and fewer people feel comfortable breastfeeding or seeing others breastfeed. This targeting and blaming of mothers for low nationwide breastfeeding rates has the potential to cause distrust by mothers—not only for the breastfeeding intervention, but also for public health interventions at large. These mothers who feel attacked by public health, the source of the campaigns, will be less likely to embrace future public health interventions. The intervention could be implemented in a manner that is effective by utilizing social science principles and perspectives, such as Social Expectations Theory, Framing Theory, and Stigma Theory. Had focus groups been held with mothers the DHHS could have learned about the social and legislative barriers to breastfeeding for a mother in the United States and appropriately set the audience, message, and destination to battle the barriers to breastfeeding instead of battling the mothers.

1. Parker, L. 2001. Breast-feeding and cancer prevention. European Journal of Cancer. 37:155-158.
2. Lightfoot, T.J. 2005. Aetiology of Childhood Leukemia. Bioelectromagnetics Supplement. 7:5-11.
3. Lightfoot, T.J. and Roman, E. 2004. Causes of childhood leukemia and lymphoma. Toxicology and Applied Pharmacology. 199:104-117.
4. U.S. Department of Health & Human Services. (2005). National Breastfeeding Awareness Campaign—Babies were Born to be Breastfed:
5. Ryan, A.S. 1997. The Resurgence of Breastfeeding in the United States. Pediatrics. 99:12-19
6. Dewey, K. G., Cohen, R.J., Brown, K. H., Rivera, L.L. Journal of Nutrition 131: 262–267, 2001.
7. Flore, Marrecca. (2007). CDC: Almost 75 Percent of New Mothers Breastfeeding. Retrieved from Fox News:,3566,291878,00.html
8. Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., Phelan, J.C.. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatr Serv 52:1621-1626, December 2001
9. National Conference of State Legislators (updated 2008). 50 States Breast Feeding Laws:
10. La Leche League International. (2003). LLLI Center for Breastfeeding Information: US Breastfeeding Legislation, Sept. 15, 2003.
11. Fox 28 (2008). Woman Discriminated for Breastfeeding. Retrieved from Fox News:
12. Barsch, Sky. (2008) Panel finds breast-feeding discrimination. Retrieved from Burlington Free Press:
13. ABC 7 News. (2008). Breastfeeding Mother Sentenced to Jail for Postponing Jury Duty. Retrieved from ABC News:
14. NBC5i. (2008). Breastfeeding Mom Claims Salon Kicked her out. Retrieved from NBC5i:
15. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved from ABC News:
16. McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.)
17. Haynes, Suzanne. “National Breastfeeding Awareness Campaign Results-Babies were Born to be Breastfed:

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