Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Humor is Not Enough: The Failure of the “Babies were Born to be Breastfed Campaign” – Laura Dodge


The benefits of breastfeeding are enormous. For infants, breast milk contains all the necessary nutrients in the correct proportions, and also contains antibacterial factors and protective immunoglobulins, both of which are absent from formula (1). Early benefits of breastfeeding include decreased mortality in preterm infants, as well as reduced infant morbidity from gastro-intestinal, respiratory, urinary tract, and middle-ear infections (2). Impacts on maternal health include lower incidences of breast cancer, ovarian cancer, and hip fractures in women who have breastfed, compared to women who have not breastfed (2).

Despite these many health benefits, only 12% of mothers in the United States meet the World Health Recommendation of exclusively breastfeeding until six months of age (3). This public health challenge has been widely recognized in the United States. Healthy People 2010 seeks to “increase the proportion of women who breastfeed their babies” to 75% in the early postpartum period, 50% at six months of age, and 25% at twelve months of age (4). Looking at national proportions of women who breastfeed, but not necessarily exclusively, provisional data from 2005 reports that 74% of women breastfeed in the early postpartum period, 43% breastfeed at six months of age, and 21% continue to breastfeed at twelve months of age (5). Increased breastfeeding is also a major program area of the Center for Disease Control and Prevention’s State-Based Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases.

In order to increase the proportion of women in the United States who breastfeed, a major media campaign was launched with the tagline “babies are born to be breastfed.” While this effort focused on an important public health issue, the campaign itself was fatally flawed in three main ways. First, it failed to address the structural barriers to breastfeeding, such as lack of support from the medical community, employers, and society in general. Second, the campaign took a “one-size-fits-all” approach, without tailoring the message to certain high-risk groups. Finally, and perhaps most importantly, the campaign failed to provide women with tools to overcome these barriers and make breastfeeding a viable option in their lives. The campaign will be redesigned as a three-pronged approach: one prong will focus on alleviating structural barriers, the second prong will diversify the message to appeal to high-risk groups, and the final prong will modify each message to include resources that can be used individually. Instead of being based on the Health Belief Model, as the original campaign was, the redesigned campaign will be based on Social Norms Theory and the Theory of Planned Behavior.

About the Campaign

The “Babies Were Born to be Breastfed” campaign was launched June 4, 2004 by the US Department of Health and Human Services (HHS) Office on Women’s Health, in conjunction with the Advertising Counsel (6). The campaign designed provocative and attention getting public service announcements, featuring posters containing images that were reminiscent of breasts and nipples, and television ads that showed heavily pregnant women engaging in risky behaviors such as log rolling and mechanical bull riding. Dr. Cristina Beato, a member of the campaign team, explained “these new public service announcements speak to parents clearly about the consequences of not breastfeeding, which may help encourage more mothers to initiate and continue to breastfeed exclusively for six months” (6). By telling women “you wouldn’t take risks before your baby’s born; why start after?” the campaign emphasizes the health risks of not breastfeeding. This is consistent with one of the aims of the Health Belief Model (HBM), which seeks to increase the perceived susceptibility to the disease as well as the perceived severity of the disease (7). This campaign is trying to increase women’s perceived severity of not breastfeeding their infants. The HBM assumes that women are in control of their own lives and are the sole decision makers about their health behaviors. However, using the HBM as a basis for this national campaign was a fatal flaw because it failed to recognize the existence of more important group-level factors.

The Campaign Failed to Acknowledge of Structural Barriers to Breastfeeding
Lack of Support from the Medical Community

In line with the Health Belief Model, the “Babies were Born to be Breastfed” campaign holds women to be individually responsible for failing to breastfeed their babies. In doing so, it disregards the complexity of the situation. The first few hours after birth are critical to breastfeeding initiation. As almost all infants in the US are born in hospitals, the hospital is a crucial influence on breastfeeding initiation (8). Many women rely on support from hospital staff when starting to breastfeed because a majority of new mothers find the initiation process to be difficult (9). If the hospital staff is unable or unwilling to assist new mothers in breastfeeding their infants, the mothers may give up. This is especially discouraging in light of hospital policies that allow free formula samples to be given out on Labor and Delivery, which have a disproportionately negative impact on women who are particularly vulnerable, including first-time mothers, minorities, and women with less education (10). Women who have just given birth are often physically and emotionally tired, and if the hospital does not assist a woman in initiating breastfeeding, a woman is more likely to look to infant formula as an attractive and convenient alternative. In this respect, the campaign fails to provide women with the tools and resources needed to encourage breastfeeding when support from the medical community is lacking.

Here, the campaign will be modified to promote institutional changes through meetings with high-level hospital administrators. This portion of the campaign will not be publicly visible, but will encourage hospitals to adopt on components of the Baby Friendly Hospital Initiative, which a Cochrane review found to result in greater breastfeeding (11). The campaign will emphasize the potential for lowered health care costs resulting from increased rates of breastfeeding among its patients (12). In addition, the components of the Baby Friendly Hospital Initiative will be low-cost to the hospital, and will include assisting mothers to begin breastfeeding within 30 minutes of birth, rooming-in, and not giving out pacifiers or free formula samples (11). Because the costs are low and the potential benefits are high, hospitals will be interested in implementing the changes promoted by the revised campaign (12).

Discouragement from Employers of Working Mothers

The second area of structural barriers that the “Babies were Born to be Breastfed” campaign does not address is the difficulty working mothers face when they return to the workforce. Approximately 70% of employed mothers with children under the age of three work full time (13). Of these women, one third of them return to work within three months of giving birth, and two thirds return within six months of giving birth (13). Working outside of the home is related to decreased duration of breastfeeding and also less frequent initiation, probably because of the multiple barriers that exist in the workplace (14). These barriers include a lack of flexibility in the daily work schedule to allow for milk expression, lack of accommodation to pump or store milk, concerns about lack of support from employers and colleagues, and real or perceived low milk supply (15-17). All of these barriers are structural in nature, and none are under individual control. Individual women cannot be reasonably expected to change these situations alone, and the “Babies were Born to be Breastfed” campaign is unable to help them. In fact, the campaign has the potential to make mothers feel guilty that they are not breastfeeding, when in fact they are up against institutional-level barriers they have no reasonable amount of control over.

Here the campaign will be modified with ads targeted to employers based on the Theory of Social Norms (18). These ads will feature breastfeeding as a normal and healthy behavior in an attempt to make breastfeeding seem like a practice worthy of workplace support. In addition, the ads will inform employers that breastfeeding results in lowered health care costs, which may benefit the employer’s bottom line (12).

Lack of Community Support for Breastfeeding

The third area that the “Babies Were Born to be Breastfed” campaign fails to address is the difficulties associated with breastfeeding outside the home, due to lack of support in the community. Many women feel uncomfortable breastfeeding away from the home, which is unsurprising (19). Although breastfeeding in public is legal in all 50 states, many breastfeeding women have been asked to leave stores and restaurants for being “indecent,” and many worry about being charged with indecent exposure (20). Resources exist for breastfeeding mothers that explain their rights, and have suggestions for what to do in situations where they are unfairly asked to leave a public place. Unfortunately, the campaign does not provide women with similar resources. Gaining public acceptance and support for breastfeeding should be a priority for breastfeeding advocates, because normative health beliefs are heavily influenced by one’s environment (18). An environment that is accepting of public breastfeeding is itself likely to encourage more women to breastfeed. The awareness that the campaign is trying to raise surrounds the health dangers of not breastfeeding, and unfortunately, this is unlikely to positively influence society’s view of breastfeeding in public. Again, the campaign is hobbled by the HBM by focusing on the individual. Without an effort to increase public support for breastfeeding away from the home, it is unlikely that large gains will be made in the proportion of mothers who breastfeed their infants.

The campaign will be revised to include a component of Social Norms Theory to normalize breastfeeding. Celebrity supporters should be sought out to assist in the campaign, such as actor Angelina Jolie, who was photographed breastfeeding one of her newborn twins for the November 2008 cover of W Magazine (21). Public figures who treat breastfeeding as a normal activity can help to change the collective perception of it from something embarrassing to something admirable.

The Campaign was “One-Size-Fits-All”

Certain groups are much less likely to breastfeed than others. Women who are younger, less educated, and have lower incomes are less likely to initiate breastfeeding and more likely to discontinue breastfeeding early, than their older, more educated, and wealthier peers (22). In the United States, being under the age of 20, having a high school education, and living below 100% of the federal poverty level are all associated with a rate of roughly 8% exclusive breastfeeding at six months of age (22). This rate increases to roughly 60% for any breastfeeding at six months of age (22). Maternal age of 30 and above, being a college graduate, and living above 350% of the federal poverty level, on the other hand, are each associated with rates of exclusive breastfeeding at six months of age of roughly 16%, which increases to nearly 80% for any breastfeeding (22). However, the “Babies Were Born to be Breastfed” campaign made no distinction between any groups. Although the campaign sought wide appeal through its humor and provocative nature, it would have benefited the campaign to tailor its message to sub-populations, instead of assuming that every individual is just like every other individual. At-risk groups such as young women, less-educated women, and low-income women are the most in need of intervention and have the potential for greatest success.

To address this issue, the campaign will be modified to target these specific populations through diverse messages in a range of locations. For instance, younger and less educated women will be targeted with ads placed in schools and youth centers. Breastfeeding will be presented to low-income women as a free alternative to formula feeding, as well as a way to lower health care costs (18). These ads will be located in public agencies that assist low-income women, as well as community health centers and supermarkets. By making the message relevant and accessible, women are more likely to listen to the message and make the proposed behavior change.
The Campaign Failed to Provide Women with Tools to Change their Behaviors
One of the claims of the “Babies were Born to be Breastfed” campaign was that it “will provide women with the information and the motivation to breastfeed (23).” While information alone can be empowering, sometime it is not enough to tell women what they should be doing without showing them exactly how to do it. Because most women already know that breastfeeding is better than bottle-feeding, the women who do not breastfeed may already feel inadequate and guilty (23). This campaign could have easily made them feel more hopeless and inadequate by not providing them with any guidance on how to change their behavior.

It is puzzling that resources were not provided in this campaign, since study staff did seem to be aware of the need for increased information and encouragement. Acting Assistant Secretary of Health, Dr. Cristina Beato, acknowledged “new parents are often discouraged from breastfeeding because of confusion about duration and doubts about their ability” (23). It is unclear how study staff expected the campaign to affect these doubts about personal ability. The Health Belief Model does not take self-efficacy into account, unlike the Theory of Reasoned Action and the Social Cognitive Theory (24,25). Women who lack a sense of self-efficacy about breastfeeding would not have benefited from the campaign because the campaign did nothing to increase their confidence in their abilities.

Previous breastfeeding campaigns were successful in educating the public about the health benefits of breastfeeding, and this campaign is simply a renovated continuation of those efforts. This failure is a result of basing the intervention on the Health Belief Method. Because the HBM is concerned with changing perceptions of severity and susceptibility, it neglects the how of behavior changes, as well as how attitudes play into decision-making regarding health behaviors, and the importance of self-efficacy in making changes to health behaviors. Even if women’s perceptions of severity are heightened by this campaign, they are left alone in deciding exactly how to incorporate the change into their lives.

The revised campaign will use the Theory of Planned Behavior to address the important concept of self-efficacy (24). As the original campaign correctly acknowledged, confidence in the ability to breastfeed will have a large impact on whether or not a woman actually breastfeeds. The revised campaign will touch on the first two prongs and seek to show women the how in addition to the why. First, it will provide resources for women who encounter barriers to breastfeeding at an institutional level. Pamphlets will be developed to inform women of barriers in the hospital, which they may not be aware of. These materials will educate women about hospital policies and encourage them to speak with the hospital staff about their desire to breastfeed, which may result in greater rates of breastfeeding initiation. The pamphlets will be distributed to medical offices and childbirth education centers. Additional materials will be developed to inform women of their right to breastfeed in public. The materials will give sample responses that women can use if someone asks them to leave a public space because they are breastfeeding. By providing with concrete examples that can improve self-efficacy, women may be more prepared to defend themselves against these barriers. Online and telephone resources will also be listed where women can find support from other breastfeeding mothers, as well as lodge complaints about businesses that are not breastfeeding-friendly. All of these resources will be printed on all of the campaign posters, regardless of the target population, because each target population can benefit from the full use of these resources.

Second, the revised campaign will not chastise women for “risking” their baby’s health, which is patronizing and may actually reduce self-efficacy. Instead, the campaign will provide women with contacts for groups that provide breastfeeding support, such as La Leche League. When available, local organizations where women can find peer support will also be provided. These resources will help women make breastfeeding a realistic part of their lives, instead of scolding those who are unable to breastfeed or have been discouraged by institutional barriers. These resources will also be printed on all the campaign posters and materials.


Undoubtedly, breastfeeding needs to be encouraged. However, the “Babies Were Born to be Breastfed” campaign is an example of how not to structure a national campaign to boost the proportion of breastfeeding mothers. By focusing on individual factors, the campaign neglects the larger structural factors that act as enormous barriers to women, including lack of support from the medical community, employers, and society in general. These structural factors are critical barriers to breastfeeding. In addition, by not tailoring the message to high-risk groups, the campaign missed out on the huge gains that could have been made in these populations. Finally, and perhaps most importantly, the campaign failed to truly empower women to breastfeed by not giving them the tools they needed to be successful. Because it was based on the Health Belief Model, this campaign is subject to the shortcomings on the model as a whole. By turning away from the influence of the Health Belief Model to instead focus on Social Norms Theory and the Theory of Planned Behavior, the campaign will be able to address institutional barriers, target specific at-risk populations, and improve individual self-efficacy. It will do this through targeted campaigns to the medical community, marketing of new social norms to society, tailoring the message to specific populations, and improving self-efficacy through the provision of resources. Breastfeeding is an important public heath challenge that has the potential to benefit greatly from a thoughtful and effective campaign.

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(20) National Conference of State Legislatures. 50 states summary of breastfeeding laws.
(21) W Magazine, November, 2008.
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