Challenging Dogma - Spring 2011

Wednesday, May 18, 2011

Increasing Breastfeeding Rates in the United States: A Mother’s Burden or a Needed Make-Over in Society? –Michelle Berardi

Breastfeeding is recognized worldwide as the most beneficial source of infant nutrition (1). The World Health Organization (WHO) recommends that infants be exclusively breastfed for the first six months of life to ensure that they grow and develop and achieve optimal health (2). Currently in the United States, 75% of infants were ever breastfed (3). This proportion is much lower than the percentages of infants in other developed nations. In Norway and Sweden, 99% and 98% of infants were ever breastfed, respectively (4,5). In Australia 88% of infants were ever breastfed (6). The disparities between the US and other developed nations are even more striking at six months. At six months, only 13.3% of infants in the US are exclusively breastfed, compared to Norway (50%), Sweden (53%), and Australia (47.1%) (3-6).

The United States’ Healthy People 2020 Objectives have set goals for the United States of 81.9% of infants ever breastfed and 25.5% exclusively breastfed at 6 months (7). The country’s current approach to this crucial public health issue is based on changing the behaviors of individual mothers. Pro-breastfeeding campaigns relying on extolling the benefits to infants and mothers if a mother chooses to breastfeed her child. The increase in breastfeeding initiation rates that the US has achieved in recent years indicates that mothers are making the choice to breastfeed. However, the low rates of breastfeeding duration indicate that barriers to continued breastfeeding cannot be overcome by an individual-level approach.

The Decline of Breastfeeding in the United States

Breastfeeding rates in the United States experienced a dramatic decrease in the twentieth century. In the 1920s and 1930s, evaporated milk became available as a substitute for breast milk (8). Evaporated milk was inexpensive and several clinical studies at the time claimed that babies fed evaporate milk formulas were as well off as babies who were breastfed (8). By the 1950s, over half of babies in the United States were fed evaporated milk formulas (8). In the late 1950s, Similac and Enfamil, two popular formula brands still manufactured and used today, entered the market and began to compete with evaporated milk formulas, quickly replacing them by the 1960s. By the early 1970s, over 75% of babies in the United States were fed commercially produced infant formulas (8). Aggressive marketing strategies by formula companies dramatically influenced the decrease of babies who were breastfed in the United States (8,9). These marketing strategies still exist today. One of Similac’s 2009 advertising campaigns for its Advance Infant Formula uses slogans such as, “You’ll feed his imagination, and we’ll help feed his immune system” (10).

The second wave feminist movement is often cited as a source of the decrease in breastfeeding rates in the United States (11). Women moved into the public sphere, embracing a definition of femininity that was not centered about motherhood (11). Formula became the way for a working mother to return to the workforce soon after the birth of her baby. Breastfeeding became something that confined a woman to her mother role and excluded her from participating in the workplace (11).

This movement also resulted in women celebrating breasts as sexual rather than maternal objects (11,12). In the United States, breasts are depicted as sexual objects rather than a means of providing nutrition to an infant. Some people get visibly uncomfortable around a woman who is breastfeeding. The idea of maternal sexuality makes many people uneasy, and thus when breasts are being used in a maternal situation like breastfeeding, there is much discomfort and controversy. For example, in the 1990s, Janet Jackson posed topless on the cover of Rolling Stone Magazine with her jeans unbuttoned and what appears to be male hands holding and covering her breasts (12, 13). The cover story is about Jackson embracing her sexuality. There was little to no public out-cry about this cover. However, in 2006, when BabyTalk Magazine published a cover with a nursing baby on a woman’s breast in an effort to promote breastfeeding, there was outrage (12,14). The public and the media have no problem depicting breasts in a sexual manner, but when they are presented in a maternal context, it is deemed inappropriate. The number one reason women who initiate breastfeeding cite for discontinuing is embarrassment in public when breastfeeding (15).

The declining rates of breastfeeding women in the United States throughout the 20th century led to a diminishment in the social and familial support network for breastfeeding mothers. A woman born in the 1970s and 1980s is unlikely to have been breastfed by her mother or had her mother breastfeed any of her siblings (9). When these women have children of their own, they do not have the ability to seek support from their mothers and aunts and are therefore less likely to breastfeed their own children. Their friends are also unable to provide them with a support network. Therefore, a woman is less likely to initiate breastfeeding her own child. This perpetuates the already low levels of breastfeeding initiation.

Current Approaches: Targeting Mothers

The United States’ current approach to the promotion of breastfeeding has counteracted some of the reasons for the decline in breastfeeding practices in the twentieth century. However, not all of these barriers have been addressed adequately. The approaches taken in the health care system, the workplace, and the government are targeted towards individual-level efforts. These strategies place too much weight on the belief that a mother’s decision whether or not to breastfeed is due to her character and knowledge rather than her environment.

Discussing infant feeding options and infant nutrition are an important component to prenatal care (16). Physicians, midwives, and nurses are expected to recommend breastfeeding to their patients. In statements released by the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG), these professional organizations issued recommendations for the support of breastfeeding as the optimal method of infant feeding (17,18). Providers are charged with informing their patients of the benefits of breastfeeding and encouraging mothers to breastfeed their babies for at least 6 months (17,18). This strategy relies on individual-level interventions to increase breastfeeding in the United States. Providers utilize the principles of the Health Belief Model (19) to encourage their patients to breastfeed their infants. By providing their patients with information on the benefits of breastfeeding and the potential risks of not breastfeeding, they assume that mothers will weigh these risks and benefits to make a rational decision to breastfeed. While this strategy may affect the intentions of mothers to breastfeed, it does not necessarily determine behaviors. This approach may partially explain why a large percentage of mothers initiate breastfeeding but do not continue.

In addition to utilizing the Health Belief Model, health care providers also employ the principles of the Theory of Planned Behavior to influence breastfeeding practices (20). Mothers respect the recommendations of their prenatal care providers and look to them for advice and guidance. By using an influential person to make recommendations encouraging breastfeeding, this strategy attempts to increase breastfeeding rates. However, this individual-level theory also assumes that the intentions of mothers to breastfeed determines their behaviors and neglects to account for social and cultural influences. While providers and other health professionals are valuable resources for increasing breastfeeding initiation and duration rates in the United States, attempting to affect change through individual patient-provider interactions is not efficient or effective.

There are several federal policies and programs aimed at increasing breastfeeding initiation and duration rates. Many states have statutes in place exempting breastfeeding mothers from being charged with “indecent exposure” if they are breastfeeding in public (21). While these laws protect mothers from being prosecuted on the basis of exposing their breasts while breastfeeding, they do not explicitly permit mothers to breastfeed in public. There are many examples of situations where breastfeeding women were asked to leave restaurants and other public places (9). There is no federal legislation granting mothers the right to breastfeed where ever they chose. This is indicative of the lack of federal and legislative support for breastfeeding and demonstrates lack of support from society as a whole for breastfeeding.

The United States Department of Agriculture, through its Women, Infants, and Children Food and Nutrition Service (WIC), has implemented policies, programs, and campaigns to encourage low-income mothers to breastfeed. Discounts on breast pumps, breast shells, and other nursing supplements as well as additional food package benefits and peer counselors are available for WIC participants who breastfeed (22). While these policies and programs remove some of the barriers to breastfeeding initiation and duration, they also fail to address some of the broader social barriers.

The Centers for Disease Control and Prevention (CDC) also issues factsheets and recommendations to encourage breastfeeding. Their objectives are targeted towards increasing mothers’ knowledge and education about the benefits of breastfeeding as well as encouraging providers and health care facilities to recommend and support breastfeeding (23). These methods employ the strategies of the Health Belief Model and the Theory of Planned Behavior, much like the approach taken by health care providers, and thus face similar challenges and have a limited effect on breastfeeding practices.

The Department of Health and Human Services (HSS) developed “Babies Were Born to be Breastfed,” a social marketing campaign to increase breastfeeding rates in the United States. This campaign used a variety of television, radio, and print advertisements to emphasize the risks of not breastfeeding. Pregnant women were the main targets of the campaign. In one of the television advertisements, a pregnant woman was depicting participating in Roller Derby, a dangerous and strenuous sport, while a voice-over asked, ““You’d never take risks while you’re pregnant. Why start when the baby’s born?”(24) These advertisements used fear to illicit behavior change. The strategy of this campaign was to utilize the Health Belief Model and overemphasize the risks of not performing the wanted behavior (breastfeeding). This approach also attempted to work on an individual level and failed to provide the necessary changes in social attitudes needed for the success of increasing breastfeeding rates.

The attitudes and beliefs of the American workforce also provide barriers to increasing breastfeeding initiation and duration rates in the United States. There is little support for women in the workforce who wish to breastfeed. The United States government mandates that 12 weeks of maternity and paternity leave be provided (25). This leave is unpaid. Often women cite the length of this period as being too short to initiate and sustain a breastfeeding regimen (11). In addition, very few work places provide nursing facilities and the appropriate accommodations for nursing mothers, especially for women who are paid hourly (25). Hourly workers have more difficulty finding time throughout the day to pump milk because they do not receive enough or lengthy breaks (25). There is also not often a place in which the nursing mother can go to pump breast milk in private; she is often forced to use the restroom (11, 25). Women who are salaried can more easily take the appropriate break time to pump (11). However, designated pumping facilities are often not available for their use either (11). Mothers with jobs in management or other similar higher positions are often able to utilize their private offices, but some still report feeling embarrassed or uncomfortable to be pumping breast milk while at work (11, 25). These women must also often approach their bosses and supervisors themselves in order to arrange for the appropriate accommodations. This places the burden of balancing work and breastfeeding on the individual and fails to address the larger social issues.

Taking the Social Route

While educating mothers and the public about the benefits of breastfeeding is important, strategies targeted primarily towards individuals are largely ineffective, especially in the context of breastfeeding, an issue with deep social influences. Through the creation of policies, programs, and regulations, the United States can incorporate breastfeeding back into the cultural norm. By utilizing strategies that embrace the more sophisticated psychosocial theories on human behavior, the United States can increase both breastfeeding initiation and duration rates.

The Baby-Friendly Hospital Initiative (BFHI) is an international program sponsored by WHO and UNICEF. The goals of BFHI are to support and encourage breastfeeding by recognizing hospitals and birthing centers that provide optimal levels of care for infant feeding (26). Hospitals and birthing center are assisted by BFHI in providing mothers with the information, support, and skills required to successfully breastfeed or, when necessary, formula feed their babies. The CDC recommends and recognizes the Baby-Friendly Hospital Initiative as an intervention that promotes breastfeeding and overall general good health of newborns and infants. International data supports the positive impact of BFHI on breastfeeding initiation and duration rates (27). As of March 31, 2010, there were less than 100 Baby-Friendly Hospitals in the United States (26). Hospitals and providers can encourage a shift in cultural norms by pushing for more hospitals and birthing centers in the United States to become Baby-Friendly. Baby-Friendly hospitals and birthing centers create an environment in which breastfeeding is the norm. As more and more hospitals and birthing centers become Baby-Friendly, more people in the United States are exposed to breastfeeding. Eventually, the adoption of breastfeeding as a social norm occurs. This strategy utilizes the concepts of the Diffusion of Innovations Theory (28) to change the behavior of a group, rather than an individual.

The federal government can also utilize strategies that target the behavior of groups in order to change the cultural norms for breastfeeding practices and increase breastfeeding initiation and duration rates in the United States. By creating federal laws that give women the right to breastfeed their infants and children in public, they influence the construction of societal ideals and norms. Congress should promulgate laws that make it illegal for a breastfeeding woman to be prohibited from any place on the basis of breastfeeding. Formal legislation on this matter will reflect to the public that breastfeeding is a priority for the health and well-being of children and mothers in the United States.

The United States Department of Agriculture, the Centers for Disease Control and Prevention, and the Department of Health and Human Services, instead of using interventions based on an individual level to educate and promote breastfeeding, should take advantage of prudent marketing strategies to influence cultural attitudes about breastfeeding. These government agencies should use their power and influence to bring the lack of support for breastfeeding mothers to the forefront of the public’s attention. By using Agenda Setting Theory (29), these agencies can help facilitate the creation of laws and regulations to support breastfeeding mothers and families.

In addition, these agencies can use Advertising Theory to develop an effective breastfeeding campaign. Advertising theory has three basic concepts: promise, support, and core values (30). By designing and implementing a social marketing campaign based on these tenets, the USDA, CDC, and HHS will be more successful in promoting breastfeeding and increasing breastfeeding initiation and duration rates in the United States. In order to effectively market breastfeeding, large promises should be made, visual images and sounds should be used as support for the promises, and core values must surround the advertisement. Advertisements depicting healthy, happy babies and mothers will appeal to the universal core values of family and love. Television, radio, and print advertisements that frame breastfeeding in a way that makes the practice a natural and “normal” part of everyday life would be the most successful because it would also utilize the principles of the Social Expectations or Social Norms Theory (31).

For example, a television advertisement could feature a man dressed in a cap and gown walking across a stage to accept his college diploma with the frame shifting to his mother in the audience, clapping, with teary eyes. In the next frame, we see a younger version of the mother contentedly breastfeeding an infant. Then there could be some text about breastfeeding supporting early brain development. This advertisement offers the promise of success and intelligence through breastfeeding. It supports these claims by showing the man receiving his degree and through the flashback of the mother breastfeeding her son as an infant. And the entire advertisement is surrounded by the core values of love, family, and power.

Interventions in the workplace must also be used to ensure that women who return to work after giving birth feel comfortable enough to continue breastfeeding. Laws at the federal level which influence leave for mothers and accommodations for nursing mothers in the workplace will help to increase breastfeeding duration rates. Federal laws mandating longer maternity leaves places more emphasis on the importance of families and will provide mothers with more support for continued breastfeeding. Companies should also adopt policies that create the appropriate for nursing mothers at all levels. Designated rooms with locks on the door that are not a part of women’s restrooms should be made available to nursing mothers to pump. In addition, pumping breaks as needed should be allowed. These policies and accommodations should already be in place without a new mother being required to request them, thus demonstrating the support of breastfeeding mothers in the workplace and signaling the cultural norms surround breastfeeding.

Society, Not Mothers

The United States’ current approach to increasing breastfeeding rates places an emphasis on changing the behaviors and attitudes of mothers. Interventions and strategies employed on the individual level have limited effectiveness in changing behaviors, especially in the long-term. The increases in breastfeeding initiation rates in recent years can be attributed to individual factors and the use of the Health Belief Model and the Theory of Planned Behavior. Statements from professional organizations like the AAP and ACOG have demonstrated the need and importance for physicians to support breastfeeding. Individual providers have worked to better inform and educate their patients about the benefits of breastfeeding and have encouraged mothers to breastfeed. The strategies employed by government agencies to warn mothers of the risks of not breastfeeding, such the campaign sponsored by HHS, have also used the Health Belief Model to convince mothers to breastfeed. However, the success of these strategies is limited in that mothers became more likely to initiate breastfeeding but quickly discontinued the practice when social support was lacking in places such as the workforce. When making a decision to breastfeed, an individual mother must consider factors beyond the risks and benefits of the practice.

The low proportion of women continuing to breastfeed their infants for the first 6 months of life is a result of the attitudes and views of breastfeeding in American culture and society. Many women who are mothers today were not breastfed by their own mothers. Therefore, they are missing need social support to breastfeed themselves. In addition, breasts are sexualized in the United States, making many women feel insecure, embarrassed, and uncomfortable with breastfeeding outside of their homes. This makes it difficult to return to work or to carry on one’s life following maternity leave. In order to increase breastfeeding duration rates, the United States must approach this issue with a social lens and work on changing the beliefs and attitudes of Americans in order to change social norms. The behavior of groups rather than individuals must be targeted. The implementation of the policies of the Baby-Friendly Hospital Initiative in more and more hospitals across the United States will help to create a cultural basis for breastfeeding and breastfeeding support. By bringing these issues to the forefront of the public’s concern, the CDC and WIC can help in pressuring Congress to create laws that protect and encourage breastfeeding mothers in public and in the workplace. In addition, the use of effective marketing strategies by government agencies when designing breastfeeding campaigns will also help to change social attitudes towards breastfeeding. In order to successfully increase breastfeeding rates in the United States, the broader social issues and the environment in which women breastfeed must be considered.

References

1. World Health Organization; UNICEF. Global strategy for infant and young child feeding. (2003) Available from: http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html

2. World Health Organization. Statement: Exclusive breastfeeding for six months best for babies everywhere. (January 15, 2011) Available from: http://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/index.html

3. Centers for Disease Control and Prevention. Breastfeeding Report Card, United States: Outcome Idicatiors.(2007) Available from: http://www.cdc.gov/breastfeeding/data/reportcard2.htm

4. Lande B et al. Infant feeding practices and assciated factors in the first six months of life: The Norwegian Infant Nutrition Survey. Acta Paediatrica, 2003, 92:152-161.

5. Sveriges officiella statistik och Socialstyrelsen. Amning och föräldrars rökvanor. Barn födda 2007 [Breastfeeding and smoking among parents of infants born in 2007]. Stockholm, Sweden: Sveriges officiella statistik och Socialstyrelsen, 2009

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