Breastfeeding as a Public Health Issue: Planning Promotional Campaigns

Ted GreinerLa Leche League Conference, Washington DC, July 3, 2005

First steps

Find out the current situation with respect to: Initiation rates Exclusivity Duration of both exclusive and continued breastfeeding

Decide which of those do you want to focus on and improve

Exclusivity is usually the one farthest from the ideal but the most complex one to work on

The Components

Protection (Making the price of reducing breastfeeding higher

than the money companies can make doing so)

The Components

Support Trained, kindly and

empowering health workers A human rights infrastructure to

support the needs of the working mother (pumping is not a strategy—it’s a coping mechanism)

Photo: Baby Milk Action – UK.

The Components

Promotion Use of face to face and mass

media communication channels to change perceived norms

Brazilian video

Initiation of breastfeeding

When women deliver in hospitals, the Baby Friendly Hospital Initiative can have an impact

Caution: health workers can be unkind and this will result in “side effects” such as backlash and avoidance (home delivery/private health care alternatives)

Promotion of increased duration

Where the norm is to breastfeed relatively exclusively for several weeks, extending this will be relatively simple but achieving 6 months for most mothers may not be

Promotion of increased duration

Extending the period of continued breastfeeding is the simplest breastfeeding behavior to influence Sometimes must address myths

or taboos Health care and maternity support

are no longer limiting factors

Extra problems in “disturbed” settings

Mixed feeding from the outset Free samples in hospital Early intensive pacifier use Concerns about infant sleep (where and

amount) Lack of human rights orientation and thus of

humane maternity benefits

Increasing the incidence and duration of exclusive breastfeeding

Must give separate attention to “prelacteal feeds”

Delayed initiation or colostrum avoidance are sometimes important as well

Note the difference between levels of “current status EBF” and “EBF since birth”

Why don’t mothers breastfeed exclusively?

• Lack of knowledge (as exclusive breastfeeding becomes the norm, knowledge spreads and the search for knowledge increases)

• Lack of support for the working mother to be with her baby

Why don’t mothers breastfeed exclusively?

• Lack of lactation management/breastfeeding counseling

• Lack of confidence (confidence likely to increase as knowledge increases)

Lack of knowledge

In a study in both rural and urban Morogoro, Tanzania, there were no determinants of EBF except knowledge*

Interpretation: you may not get EBF just by conveying knowledge about it, but without that knowledge it is definitely absent because it is the norm almost nowhere

*Shirima R, Gebre-Medhin M and Greiner T. Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania. Acta Paediatrica 90:936-942, 2001.

Time with the baby

Europe got long family leaves (often about a year) because: Women voters made it a political issue Women were unwilling to have any or many

babies unless they got it (low fertility rates) There is no link to breastfeeding Pressure to require men to take as much as

women

Support for doing it right

In any culture several % have incorrect positioning or poor latching on

Health workers are rarely trained well, though improving, especially in places where EBF is normative (parts of Scandinavia and Canada)

When initiation and duration increased in the 1970s and in exclusivity in the 1990s, health worker capacity increased AFTERWARDS

Relation between support and promotion

Increasing the desire to breastfeed exclusively without providing the required support, will give limited results and may increase backlash

Investment in support ALONE works poorly: Health workers in isolation (eg BFHI with too

little effort on Step 10) have limited impact Improved maternity protection will have little

impact (eg day care near the home)

Lack of confidence

Empowering women does not appear to lead to a decline in breastfeeding

To the contrary, powerful women transform society to meet their reproductive as well and productive needs

Harm may be unwittingly done by over-emphasizing the importance of good diet during lactation

Health workers almost never empower (partial exception: midwives)

BF promotion methods of proven effectiveness

Educating mothers during pregnancy; can be in small groups

Evidence for impact: the most effective intervention for initiation and short-term duration

Contents: Benefits to baby, mother, society Positioning and latching on Needs during the early days of BF Resources for assistance Address fears, problems, myths

Professional support

Help with positioning, latching on, solving problems

Both pre and postnatal Best from IBCLCs or Best Start 3-step Counseling Strategy Evidence for impact: “fair evidence” it

increases duration if “in-person” not via telephone contact

Mass media and social marketing

Comprehensive, multifaceted Variety of audiences (important to segment) Evidence of impact:

improves attitudes Increases initiation rates and possibly duration

Countermarketing and the Code

Commercial discharge packs reduce exclusive breastfeeding at all ages

Educational materials from infant formula companies reduce exclusivity and duration

The Code forbids advertising, free samples, idealizing pictures on labels, gifts to health workers, sales incentives, and requires label warnings

Professional education

Basic and in-service education is required for any health professionals who deal with women pre or post-natally

But in isolation its effects are unproven Perhaps health workers also need a change

in job description that gives them an opportunity to put their new knowledge into action

Public acceptance

Legislation ensuring the right to breastfeed Support to public breastfeeding Including breastfeeding in school curricula Too little research to know about

effectiveness

Provision of information

Providing printed materials alone has no impact

Nor does giving a simple message to breastfeed or do so for a longer period of time

Hotlines and web-based support have not been evaluated

Information is usually part of multifaceted breastfeeding interventions which have been shown to increase initiation and duration

Peer counseling

Usually based on training volunteers who schedule 6-15 postnatal home visits during the early months

Has been shown to lead to a dramatic increase in exclusivity, but not in the US or the UK

Probably more effective if volunteers are organized in “Care Groups”

Norms*

At what point does something become the norm? Descriptive norms relate to “what everyone does” Injunctive norms put pressure on us (via the threat of

social sanctions) Perceived norms may differ from actual norms in both

cases Mass media and face to face communication can

influence our perception of what is the norm

*See: Lapinski and Rimal. An explication of social norms. Communication Theory 15:127-147, 2005.

Moderators in the influence of descriptive norms, I

Perception of benefit (outcome expectations)

Shared affinity with referent group (strongly identifying with the group)

Culturally determined view of the importance of the collective vs the individual

Extent to which an attitude or behavior is viewed as central to my self-concept

Moderators in the influence of descriptive norms, II

Ambiguity (new behavior; new culture) heightens our use of others’ behavior as a guide to our own (reach women before or during 1st pregnancy)

Whether the behavior is enacted in a public or private setting (privacy reduces our knowledge of norms and eliminates injunctive norms)

Most powerful: combination of descriptive norm and perception of benefit (threat of losing something is a greater motivator than opportunity to gain an equal amount)

Who’s against breastfeeding promotion?

People who’ve been treated cruelly People who feel guilty People with a free market political agenda Baby food companies and others with vested

interests Efforts to reduce backlash should focus on

reducing the first of these, sympathizing with the second and exposing the others’ true motives

From the baby’s point of view

If babies had a voice they would universally demand that society take steps to enable them to be breastfed

They’d probably be understanding in cases where it caused serious conflicts or problems for mom

Take home lesson: put pressure on everyone else, but not mom

Recommendations for breastfeeding promotion campaigns, I

Focusing ONLY on a Code of Marketing, health worker training or improvements in maternity benefits will have only a marginal impact

Exclusive and continued breastfeeding must become the norm first or simultaneously

Mass media can help (both increasing the positive mention of breastfeeding and decreasing the normative presence of artificial feeding)

Recommendations for breastfeeding promotion campaigns, II Texas Dept of health MediaWatch

Campaign (www.dshs.state.tx.us/wichd/lactate/media.sthm)

Work on moving breastfeeding from the private to the public arena will increase the potential impact of norms (+ “side effects” of new laws!)

Ignoring protection and support needs in situations where these are important constraints will limit impact and increase backlash

Recommendations for breastfeeding promotion campaigns, III

Thus health worker training and improved maternity benefits should be simultaneous with promotional/norm efforts

Not enacting a Code of Marketing is like fattening the chickens while leaving the door to their pen open to the fox