Breastfeeding Initiatives: Banning Formula is not the Answer – Kayley Pettoruto

Introduction

Epidemiologic studies have proven the numerous advantages of breastfeeding over using formula—including health, nutritional, economic, social, immunologic, developmental, social and environmental benefits (1). Breastfeeding reduces a mother’s risk of breast and ovarian cancer and reduces a baby’s risk of ear, respiratory and gastrointestinal infections, reduces rates of hospitalization, asthma, and promotes maternal bonding and optimal growth (2).

Despite these known benefits, breastfeeding rates after six –months and at one year of age are low, compared to public health goals in the United States. The National Immunization Survey of 2001-2002 estimates that more than 71.4% of children nationwide were breastfed at some point; however, that rate drops to 16.1% by one year of age (3). Unfortunately, these rates are lowest among individuals with the greatest risk of poor maternal and child health outcomes: those women of low income, low socioeconomic status, low educational attainment, and non-Hispanic black women (3). With these disparities in mind, New York City developed a hospital-based breastfeeding-only program, namely “Latch On”.

This program is a hospital-based initiative that focuses on reducing distribution of promotional infant formula and a public awareness campaign, to inform women of the benefits of breastfeeding (2). This public health awareness campaign takes form in posters in subways and hospitals (2). The program in New York City also asks that hospitals put away formula, take down formula advertisements, and advertise the health benefits of breastfeeding throughout the hospitals (2). It requires that new mothers ask for formula from the nurses instead of being given promotional material automatically. Nurses are required to discuss the benefits of breastfeeding with new mothers. By reducing formula distribution and increasing knowledge about the benefits of breastfeeding, the “Latch On” program intends to increase exclusive breastfeeding rates. (2).           

Currently 28 hospitals in the area have signed on to participate. The initiative focuses on two main health beliefs—women need accurate information in order to make the right decisions about breastfeeding and through reduction in distribution of promotional formula, breastfeeding initiation and duration rates will improve (2).

While the Latch On approach has many positive aspects to it, which are backed by research and evaluation, the program has received a lot of backlash from the public.

The Latch On Initiative even had to publish a “myths and facts” memo in order to quell some of the many myths that had arisen surrounding the program. Some of the myths included in this publication were: “formula was being put under lock and key”, “formula feeding will be forbidden in some fashion”, and probably most importantly, “Latch on NYC is taking away and/or jeopardizing a woman’s right to choose how to feed her baby” (2).

            In this critique, I will focus on three aspects of the Latch On campaign that failed when considering social and behavioral sciences. Firstly, the campaign assumes individual level factors are sufficient to promote breastfeeding. Secondly, the Latch On campaign ineffectively uses core values. Thirdly, the campaign does not use effective communications strategies, including failure to avert psychological reactance.

Critique 1: Individual Level Factors are Insufficient

Mayor Bloomberg’s Latch On Initiative assumes that individual level factors are sufficient to promote change. This construct led policymakers to create the Latch On Program, which provides information to new mothers about the benefits of breastfeeding through posters, information from hospital nurses and limits access to formula. However, the framework of the social determinants of health explains how social and community influences, living and working conditions, and general socioeconomic, cultural and environmental conditions also influence health behaviors (4).

Interventions that focus entirely on individual behavior change can be ineffective because they fail to consider the cultural, sociopolitical and economic contexts of individual health experience and behavior (5,6).

Even if women leave the hospital without formula and a wealth of knowledge about the benefits of breastfeeding, individual level interventions are not sufficient to promote change, as there are other factors women face once they leave the hospital that may or may not allow them to breastfeed. According to the literature, factors that influence the length and duration of breastfeeding include employment status (7), social support, self-efficacy, and breastfeeding experience (8). Assuming that informing women that they should breastfeed and making formula harder to obtain in the hospital setting does not in any way help women overcome these external factors. The breastfeeding prevalence data reveals that these external factors are not being considered. The major issue in the United States today is the continuation of exclusive breastfeeding, not necessarily initiation. As the data shows, 71.4% of children received breastfeeding initiation, which is a fairly substantial percentile. The problem is the sustainability of breastfeeding—the breastfeeding rate drops to 16.1% by one year of age (3). The American Academy of Pediatrics highly recommends exclusive breastfeeding through the first six months and continued breastfeeding through at least one year of age in order to ensure the health benefits (1).

Ultimately, the flaw in this campaign is assuming that individual level factors are exclusively influencing health behavior—that is, women will breastfeed if they leave the hospital without formula and with knowledge about the benefits. Breastfeeding is a very difficult process and there are many barriers beyond simply those assessed in this intervention.

 By considering only individual level factors, the Latch On program ignores the context beyond the hospital setting; they assume that women choose not to breastfeed because they don’t know the benefits. Stress, lack of social support, and work schedules are just some of the contextual factors that play a role in breastfeeding decisions (7,8). Ultimately, all women need support beyond the day of birth to ensure adequate breastfeeding practices. Simply de-promoting formula use and increasing knowledge are not sufficient.

Critique #2: Ineffective Use of Core Values

            The second critique of this campaign is the use of health as the main core value.  When developing a campaign, the core values of the messages must be consistent with American values (9). Powerful American values include individual freedom, freedom speech, and protection against racial discrimination (9) and not health. Framing an issue accurately for public approval is a very important component of public health campaigns (9). In this particular campaign, the interventionists failed at framing Latch On effectively to the public.

            A public health frame is strong if it has a strong core position, utilizes metaphors, catch phrases, symbols, and most importantly, a powerful core value (9). The tobacco industry is one such example of a campaign that has been very successful due to the nature of its core values. Despite the known negative health consequences of smoking, cigarette campaigns have been successful because they appeal to freedom, autonomy, individual rights, and economic opportunity (9). Tobacco control campaigns that have utilized the core value of health have been less successful (9).

To the left is a poster used in the campaign (10). You can see here that the main core value used is health—breast milk reduces a baby’s risk of ear infection, pneumonia, and diarrhea. Throughout reading the promotional materials, I did not come across any metaphors used in the campaign. The main symbol is the baby/infant, and the catch phrases are “Latch On”, and “breast milk is best for you’re your baby”.

            In the press release for this initiative, the State Health Commissioner, Nirav Shah, is quoted as saying, “Mothers who choose to breastfeed their baby are making a healthy choice for their child and themselves” (2). The Latch On initiative is focused solely on health as a core value, which ultimately is ineffective with the public. The framing of this particular initiative created backlash because it did not utilize core values that are important to Americans including freedom, justice, and liberty (9).

Critique 3: Failure of Health Communication Strategies

            Latch On also failed at utilizing effective communication strategies including failure to consider psychological reactance theory and failure to utilize an effective messenger.

This particular initiative took away freedom by limiting new mother’s access to formula. By putting away formula, and requiring that women request it from the nurse, women felt that their individual freedoms were being limited. One particular myth that spread rapidly was that the initiative was “jeopardizing a woman’s right to choose how to feed her baby” (2). This type of reaction is a result of the Psychological Reactance Theory, which states that any pervasive message may cause an individual to feel that their personal freedom or personal choice has been threatened (11,12). There are four main elements to psychological reactance theory: freedom, threat to freedom, reactance and restoration of freedom (11). In this case, the freedom is to receive formula in the hospital; the threat is the removal of the formula; the reactance is the anger that results; and the restoration of the freedom stage is when women go out and buy the formula to reestablish their freedom.

This type of reaction has also been referred to as the Boomerang Effect (12). Warnings, among other types of public health campaigns, sometimes produce opposite effects of those intended (12, 13). One particular example of a public health campaign that produced boomerang, or opposite effects, is the minimum age for alcohol beverages (12). Research has revealed that increasing the legal age for drinking to 21 years of age may actually have increased underage drinking (12).

In public health, policymakers should never limit individual freedoms if they want their interventions to be successful (11). Taking away formula only makes women want formula more, due to Psychological Reactance Theory.

            Psychological reactance also may have occurred because of the lack of similarity of the communicator to the targeted audience. Studies have shown that threats only cause the boomerang effect when the communicator’s similarity was low or unknown (14). When people are similar to the communicator, they agreed with the message of the campaign, regardless of threat to freedom (14). Public health campaigns can avoid reactance if they elect a communicator who is similar to the targeted audience. The Latch On campaign does not employ these communication principles. The messengers for this particular campaign are Mayor Bloomberg, the Health Commissioners, and ultimately nurses and doctors. For pregnant and nursing women, they need a spokesperson of whom is similar to them—another mother or a peer. By using health officials and figureheads, the Latch On program ideology was not relatable to their target audience. As a result, their target audience—new mothers—rejected the program.

Introduction to New Campaign

            I propose a new intervention to replace the Latch On campaign, which I believe will eradicate the three areas where Latch On failed—lack of consideration of factors beyond the individual in determining breastfeeding outcomes, ineffective use of core values, and lack of health communication strategies. Instead of focusing on knowledge and formula access, New York City public health officials should focus on antenatal breastfeeding support. The data shows that the greatest area of need is breastfeeding continuation, with only 16% of women breastfeeding their babies through year one in the United States (3). I propose allocating funding to antenatal breastfeeding peer education and group support in New York City hospitals. This particular intervention will resolve the three failures of the original campaign, by considering the context of breastfeeding, not just individual level factors; by utilizing effective core values including individual freedom; and avoiding psychological reactance through providing choices and a messenger similar to the audience.

Support #1: Breastfeeding Support, Improving the Context

            Instead of focusing on individual level knowledge and access to formula, the Latch On Campaign should improve antenatal breastfeeding support, through both support groups and peer education. Social support is highlighted as one of the most significant predictive factors of breastfeeding initiation and lengthened duration among low-income women (8)—not knowledge or access to formula, as the Latch On Program advocates. In this study on low-income women, breastfeeding experience, self-efficacy, support from the father and support from a grandmother were all statistically significant correlates to lengthened breastfeeding duration and better outcomes (8). Support is imperative to breastfeeding success long term, not simply knowledge.

Social support is powerful in public health. One particular prenatal care intervention, namely the Centering Pregnancy program, is one such example that employs social support as a mechanism to improve outcomes. For Centering Pregnancy, group prenatal care resulted in lengthened gestation and increased birth weight (15). Relationship-centered care empowers women to advocate for themselves and others and gives them a social network of who can serve as a safety net and a sounding board.  The Centering Pregnancy prenatal model of group-centered support groups can be applied to the antenatal period as well. The United Nations Children Fund and the World Health Organization published the 10 steps to successful breastfeeding (16, 19). The tenth step is “foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic” (16). Breastfeeding support groups are an imperative piece to improving breastfeeding outcomes outside of the hospital.

Breastfeeding peer counselors are another component of antenatal support.  Breastfeeding peer counselors are defined as “local community women who have experienced breastfeeding success, have been trained in breastfeeding management, and work with women of similar cultural, demographic, and socio- economic characteristics to promote positive breastfeeding outcomes” (17). Training women to aid other women with breastfeeding practices has been employed and effective in a variety of developing countries, but few in the United States (17, 20, 21). A literature review conducted by the National Institutes of Health revealed that breastfeeding peer counselors improve breastfeeding initiation, duration, and exclusivity and decreased rates of infant diarrhea (22). Studies have also concluded that breastfeeding peer counselors are effective with low income, minority women, who have some of the lowest rates of breastfeeding in the United States (17).

Combining the principles of peer education and group-centered support could help improve breastfeeding outcomes—especially for women who might not have the best context—perhaps without a supportive partner, family, safe neighborhood, among others. The creation of antenatal support groups and peer counselors could help improve breastfeeding outcomes through improving self-efficacy, knowledge, and social support for mothers. Women who are supported in their breastfeeding process will more likely succeed in persevering through the trials and tribulations of parenting and ultimately have a better chance of breastfeeding through the first year of their child’s life. Instead of taking away formula and focusing on knowledge, funding in New York City should be allocated to antenatal breastfeeding support.  Instead of putting away formula, nurses could offer a breastfeeding peer educator and/or group-centered support for women in each hospital in New York City. Immediately from the start, new mothers could have a support system that is offered to them in the hospital immediately when their baby is born. If framed and marketed effectively, this new program could be very effective.

Support #2: Effective Framing and Use of Core Values

            Using health as the main core value was entirely ineffective in the Latch On Campaign. As a result, we need to re-frame and re-package the new breastfeeding peer counseling campaign. Public health officials need to frame this campaign as a women’s choice, not a loss of freedom. Freedom and liberty are powerful core values in the United States (9), thus, any such campaign that takes away freedoms (i.e. takes away formula), will be ineffective (11,14). In addition to using powerful core value, public health officials need to employ effective metaphors, symbols, and catch phrases in the new frame.

Core Values

            Instead of framing health as the core value, employing liberty and justice as core values could be effective. Formula companies can be packaged as the enemy—their promotional strategies are infringing upon a mother’s right to choose between breastfeeding and formula. Because every hospital is covered in advertising and mothers are given formula right from the start, women are not given the opportunity to choose whether they want formula or not. Women have the right to reject the promotional strategies of formula corporations, and choose whether they want to breastfeed or not. It is one’s civil liberty to decide how they will feed their children and formula companies, like tobacco companies, are targeting new mothers, without the well being of their babies in mind. Women can make the choice to choose the peer educator and group support over formula. The “the evil formula companies” frame employs the core values of freedom and justice, which are more effective core values than the heath frame used in the Latch On campaign.

Metaphors, Symbols, and Catch Phrases

            In order to make this new frame truly effective, public health officials need to create metaphors, symbols, and catch phrases to support the frame. Metaphors and symbols should be recognizable and important to the American public in order to be effective (9). Some potential catch phrases examples include:

 “Putting mom’s back in charge”

“Taking the profit out of birth”

“It is our civil right to protect our babies”

“Take control of your baby’s outcomes. Work with a breastfeeding peer educator”

“She’s been through it before. She can help you get through it, too.”

            Some important symbols to employ are pictures of all kinds of women who serve as breastfeeding educators—of varying ages, ethnicities and races--in order to appeal to the entire NYC population of women. Posters should be available in multiple languages and focus on women’s rights and self-empowerment.

            This campaign will be more successful than Latch On because of the reframing, use of more effective core values, and appeal to the audience at risk.

Support #3: Using Effective Communications Strategies

The new campaign reduces psychological reactance because women have options. They have the option to choose between formula, or a peer educator and support groups. Giving women the option to choose increases their freedom, instead of decreasing it. By giving women options, psychological reactance is avoided. Women have the option to choose formula, but they also have the option to work with a breastfeeding peer educator and enroll in a breastfeeding support group.

Similarity of the messenger to the audience is an important component of avoiding psychological reactance (14). Breastfeeding peer educators work with women from their own community, who are similar to them in cultural, demographic, and socio- economic characteristics (17).  Because this program utilizes peers, who are similar to the women they serve, psychological reactance is also avoided.

Another pitfall of the Latch On campaign was using the Health Commissioner and Mayor as the spokespeople for the campaign. Given the nature of psychological reactance, the spokesperson for the new campaign should be a mother who breastfeeds, who is relatable to the audience. Having a celebrity endorse a campaign makes it newsworthy and often more effective (18). It could be potentially effective to use a celebrity mother as the spokesperson for this new campaign in New York City.

Conclusion

            The Latch On campaign, although well intentioned and backed with research, did not consider the predictable irrationality of human behavior and social and behavioral sciences. The program fails in three main ways. Firstly, breastfeeding outcomes are not attributed solely to individual level factors. Stress, lack of social support, poverty, working conditions all are factors that influence breastfeeding (8)—not simply knowledge. Secondly, the program uses health as a core value, which is very weak (9). Thirdly, the campaign produces psychological reactance, due to the limiting of access to formula and the dissimilar spokespeople.

            A potentially effective intervention for the low breastfeeding rates at 6 months and one year is breastfeeding peer counselors and group support sessions. Funding should be allocated to training breastfeeding peer counselors and organizing these group sessions. Nurses in hospitals should offer this program to all new mothers in the obstetrics department. This way, women can leave the hospital with a support system that can help them breastfeed. This type of program is backed by a variety research—peer educators and group support sessions are successful at improving initiation and duration of breastfeeding outcomes (16, 17, 20, 21, 22).

This new campaign corrects the errors made by the Latch On Campaign, through the use of social and behavioral sciences. Breastfeeding peer counselors and group support groups will resolve the three failures of the original campaign, by considering the context of breastfeeding, not just individual level factors; utilizing effective core values including individual freedom; and avoiding psychological reactance through providing options and a spokesperson who is similar to the targeted audience. 

References

  

1.       American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk, section on breastfeeding. Pediatrics 2005; 115(2): 496-506.

2.       New York City Department of Health and Mental Hygiene. Latch On New York City. http://www.nyc.gov/html/doh/html/ms/latchonnyc.shtml.

3.      Li R, Darling N, Maurice E, et al. Breastfeeding rates in the United States by characteristics of the child, mother, or family. Pediatrics 2005; 115(1): e31-e37.

4.      Dahlgren G., Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Futures Studies, 1991.

5.      Marks, D. Health psychology in context. Journal of Health Psychology 1996; 1(1): 7-21.

6.      McKinlay, JB, Marceau, L.D. Upstream health public policy: lessons from the battle of tobacco. International Journal of Health Services 2000; 30(1): 49-69.

7.      Anderson-Kosmala, J. Breastfeeding works: the role of employers in supporting women who who wish to breastfeed and work in four organizations in England. Oxford Journal of Public Health 2006; 28(3): 183-191.

8.     Mitra AK, Khoury AJ, et. all. Predictors of breastfeeding intention among low-income women. Maternal and Child Health Journal 2004; 8(2): 65-70.

9.      Menashe, C. & Siegel, M. The power of a frame: an analysis of newspaper coverage of tobacco issues—United States, 1985-1996. Journal of Health Communication 1998; 3(4):307-25.

10.  Oh, I. Bloomberg's breastfeeding program, 'Latch On NYC,' wants hospitals to change baby formula protocol. Huffington Post, 2012. http://www.huffingtonpost.com/2012/07/30/bloombergs-breast-feeding-latch-on-nyc-hospitals-hide-baby-formula_n_1718664.html.

11.   Dillard, JP & Shen, L. On the nature of reactance and its role in health communication.” Communication Monographs 2007; 72(2): 144-168.

12.  Ringold, DJ. Boomerang effects in response to public health interventions: some unintended consequences in the alcoholic beverage market. Journal of Consumer Policy 2002; 25: 27-63.

13.  Stewart, D. W., & Martin, I. M. Intended and unintended consequences of warning messages: A review and synthesis of empirical research. Journal of Public Policy and Marketing 1994; 13: 1–19.

14.  Silvia, P. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance.” Basic and Applied Psychology 27(3): 277-84.

15.   Zohar M, Schindler Rising S, Ickovics J. Centering pregnancy group prenatal care: promoting relationship-centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing 2006; 35: 286-294.

16.  Nickel, N., Labbok, M., Hudgens, M., et all. The extent that noncompliance with the 10 steps to successful breastfeeding influences breastfeeding duration. Journal of Human Lactation 2012; XX(X): 1-12.

17.   Chapman, DJ, Morel, K, Burmudez-Millan, Young, S. et all. Breastfeeding education and support trial for overweight and obese women: A randomized trial. Pediatrics, 2012.

18.  Aschermann-Witzel, J., Perez-Cueto, F., et all. Lessons for public health campaigns from analyzing commercial food marketing success factors: a case study. BMC Public Health 2012; 12:139.

19.  Merewood A, Heinig J. Efforts to promote breastfeeding in the United States: development of a national breastfeeding awareness campaign. J Hum Lact 2004; 20(2): 1405.  

20. Leit, AJ, Puccini, RF, Atalah, AN, et all. Effectiveness of home-based peer counseling to promote breastfeeding in the northeast of Brazil: a randomized control trial. Acta Paedrics 2005; 94(6): 741-746.

21.  Aidam, B., Perez-Escamillia, R., & Lartey, A. Lactation counseling increases exclusive breast-feeding rates in Ghana. Community and International Nutrition 2004: 1691-1695.

22. National Institutes of Health. Breastfeeding peer counseling: From efficacy through scale up. Journal of Human Lactation 2010; 26(3): 314-326.