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.

Breastfeeding-Promotion Requires Acknowledgement of Perceptions of and Barriers to Control: A Critique of the “Latch On NYC” Initiative – Marita Hatton

Several national and international institutions have championed the issue of breastfeeding for its short-term and long-term health benefits to both mothers and infants (1-2). The positive immunological and anti-inflammatory properties of breastmilk are well supported by research in the field and can contribute to a lower risk of certain kinds of infections in infants, such as ear, gastrointestinal, and respiratory infections (1). Health benefits for breastfeeding mothers include a lower risk of certain cancers, such as ovarian cancer (1). In addition to the health benefits, experts also tout the psychosocial (i.e., bonding), economic, and environmental benefits of breastfeeding (1). Economic benefits include not only the direct benefit related to averting the significant cost of formula, but also long-term indirect benefits of lower health care costs as a result of reduced illnesses and improved health conditions for mother and infant (1). The benefits of breastfeeding are generally proportional to the duration of breastfeeding, and the WHO recommends a goal of exclusive breastfeeding for at least the first 6 months and continued breastfeeding up through 2 years (2).

In many developed and developing countries, breastfeeding rates and durations have declined due to a variety of cultural and economic reasons (2). In the US, rates of breastfeeding have increased since the 1970s, when the proportion of women breastfeeding was at an all-time low, but the prevalence of breastfeeding at different times in an infant’s first year of life is still lower than the Healthy People 2010 goals (1). In May 2012, Mayor Michael Bloomberg and the New York City Health Commissioner Thomas Farley announced the “Latch On NYC” initiative to boost rates and durations of breastfeeding within the city (3-5). The initiative had two main components: a request for NYC hospitals to pledge to limit certain formula distribution practices, and a public awareness campaign regarding the health benefits of breastfeeding (4). Specifically, hospitals pledged to enforce NY State’s hospital regulation of only supplementing breastfeeding infants with formula when medically indicated and documented in the medical record, to restrict and track infant formula distribution, and to end the distribution and display of promotional infant formula materials (3). Although this initiative incorporated several of the goals in WHO’s “Ten Steps to Successful Breastfeeding,” it failed to consider the impact of a presented threat to a woman’s choice of whether or not to breastfeed, the barriers to perceived control of breastfeeding success, and the cultural norms surrounding breastfeeding in NYC (2). In light of these critical issues, the Latch On NYC initiative is limited in its potential for success as a public health intervention.

Critique #1: Latch On NYC Presented a Perceived Threat to a Woman’s Choice

One highly visible flaw of the Latch On NYC campaign is that it generated a very vocal and polarized reaction in the popular press, especially among female journalists and bloggers (7-11). Articles with titles such as “Sucking the choice out of parenting” and “Back Off of the Mamas, Mayor Bloomberg!” clearly depict some of the outrage in response to the announcement of the initiative (7-8). Such potential for negative responses could have been predicted if considering the Theory of Psychological Reactance (6). This theory, as posited by Jack W. Brehm in the 1960s, describes how people often react to a perceived threat to freedom or choice by explicitly taking an action that reinstates that freedom (6). If, for example, a person had three possible choices of how to spend their time on a given afternoon, if one of these choices is suggested to be taken away, it actually increases the person’s interest in that option, as they are motivated to reestablish the freedom of choice they had previously experienced. Thus, the person is effectively resistant to the persuasive suggestion and can be pushed toward an opposite stance. Brehm describes how individuals will demonstrate more of the negative reactance response if a large portion of their choices are threatened or eliminated, or if the threat has a substantial likelihood of being carried out (6). He also delineates how justification and legitimacy can help to mitigate the reactance response, as long as the reasons are sufficiently compelling (6).

Unfortunately, the focus of the Latch On NYC campaign on formula distribution practices in hospitals implied a direct threat to a woman’s choice of whether to breastfeed or formula-feed her newborn. Many female journalists in particular responded with outrage to this perceived threat to freedom, and others responded by championing the right to formula-feed and emphasizing the practical benefits (7-8, 12). This psychological reactance was further exacerbated by the impression of Mayor Bloomberg as having radical health policies and by the fact that the message came from the Mayor and the NYC Health Commissioner, both of whom are men and thus could have no direct experience with the factors and difficulties associated with the decision to breastfeed. One journalist wrote “We can’t imagine the mayor making these decisions for us…because obviously they’re none of his business” (7). Reports that the mayor was requiring hospitals to keep formula under “lock and key” implied the very real and severe threat to choice that Brehm emphasized as stimulating high levels of reactance (6-7). The attempts to use justification based on the health benefits of breastfeeding failed to be compelling because they came from men, and again the impact was high levels of psychological reactance (6, 8).

The Latch On NYC campaign attempted to address the public display of reactance by publishing more documentation on the initiative and creating a “Myths & Facts” document to try to address some of the negative press (5). However, as journalists and bloggers continued to emphasize, the program was trying to revoke some of the inflammatory wording, such as “lock and key,” while the key program components on restricting access to formula remained (13). In reality, these after-the-fact messages have had little power to influence the public perception of the initiative following the vocal outrage. Because it failed to recognize the significant potential for psychological reactance to the message, the Latch On NYC initiative is severely hampered in its ability to affect change in the rates of breastfeeding.

Critique #2: Latch On NYC Did Not Address Barriers to Perceived Control of Breastfeeding

            Although the WHO and the Baby Friendly Hospital Initiative emphasize important breastfeeding-promoting practices in hospitals and other maternity facilities (2, 14-15), and this was the emphasis of the Latch On NYC campaign, practices in these environments are only influencing the very beginning of breastfeeding. In light of the struggle for continued duration of breastfeeding beyond the hospital, other experts and US agencies also stress the barriers and perceived barriers that exist outside of the hospital environment (1, 16). The US Surgeon General’s report lists barriers that include poor family and social support, embarrassment and lactation problems, and issues with employment and child care, in addition to the barriers related to health care services (1).

Perceived behavioral control is an element described in the Theory of Planned Behavior, or TPB (17). The TPB is an individual-oriented health behavior theory that was developed to assess ones attitudes toward health behaviors and their resulting behavior intentions and actions. In the precursor model, the Theory of Reasoned Action, the key components influencing a person’s reasoned decision to act in a certain manner include their attitudes toward the expected outcome and the social norms regarding others’ perception of the behavior (17). The TPB builds on this precursor model in that it recognizes that real-world barriers can interfere with an individual’s ability to act in a certain way, even if that individual has very strong intention and motivation toward that behavior. Circumstances may severely limit the ability of an individual to achieve that behavior, as in the case of transportation issues prohibiting someone from seeking proper preventative medical care for a chronic disease. In the TPB, the element of perceived behavioral control includes what an individual believes about factors that will limit or enable her, as well as how much power that individual believes she has to overcome such barriers to action (17).

Perceived behavioral control and self-efficacy, or the confidence in an ability to perform a behavior, have been demonstrated as important elements in health-related behaviors such as seeking screening for skin cancers or successfully achieving a vaginal delivery (18-19). In the case of breastfeeding, women can have many perceived and actual barriers to control of realizing successful behavior. Mistry et al. describe the multi-faceted social, economic, and cultural determinants of early childhood health that are in place in the workplace, home, health care, family, neighborhood, and religious institutions and the ways these can be influenced by both private and public sector policies and programs and by strengthening the capacities of families and communities (16). The USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides nutritious food to low-income pregnant women and young children, underwent several changes in 2009 that incentivized especially exclusive and also partial breastfeeding (20). These public policy changes, combined with extensive participant education to support breastfeeding, were successful in improving the rates of exclusive breastfeeding at 2 and 6 months in a study in California (20), highlighting the success of strategies that aim to eliminate financial barriers.

Several studies also emphasize the importance of the workplace environment in facilitating successful breastfeeding (21-23). Exclusive breastfeeding rates are persistently low among women who work full-time (21), a reflection of barriers related to time, workplace facilities, and economics, among others. In the US, the Family Medical Leave Act guarantees 12 weeks of job-protected unpaid leave (16), whereas in countries such as Canada, recent changes improved on a compensated job-protected maternity leave of 6 months to up to 1 year in most provinces (23); the benefit improvement resulted in an additional 40% of women achieving the goal of exclusive breastfeeding at 6 months. Letters to the Editor in the New York Times and research studies interviewing women describe hostile workplace environments that are not supportive of women who need time and space to pump in order to sustain breastmilk after returning to work (11, 22). Such workplace barriers involve actual time and space issues, especially for women in administrative or manual positions, but they also involve the perceived control over such situations, which is something that can be addressed through proper coaching and supportive breastfeeding education (22).

Although the Latch On NYC initiative had purported aims to increase the duration of breastfeeding, it did not provide solutions outside the hospital environment, including in the workplace. As a result, women still have a perceived lack of control over some key factors influencing their ability to successfully exclusively breastfeed up to 6 months. Because the initiative does not give women this necessary control, its potential to achieve the targeted durations of breastfeeding are considerably hindered.

Critique #3: Latch On NYC Did Not Address Cultural Norms Surrounding Breastfeeding in NYC

Although the health benefits of breastfeeding are widely known in the US, the social and cultural norms are often not conducive to breastfeeding. Reports have described how public perception is not receptive to breastfeeding in public in many situations (1, 11, 25-26). Breastfeeding mothers are quite sensitive to their appearances when needing to breastfeed in public (26). There are instances when women are asked to leave or refrain from breastfeeding in public locations (27). Additionally, studies describe how ridicule from friends and family and unsupportive health care providers can also frame and dominate the social and cultural context of breastfeeding (25). In the US, despite the efforts to educate the public of the health benefits of breastfeeding, bottle-feeding is still viewed by many as the accepted social norm (1).

DeFleur described in his Cultural Norms Theory how an individual’s behavior is usually strongly influenced by social or cultural norms, and in turn how the media can be used to influence and change the social norms (24). Norms are described as the “general rules that are understood and followed by all members of a group” (24). Individuals that fail to adhere to these norms are subject to negative sanctions and may feel like social outcasts (24). In the case of breastfeeding, the cultural norms in large US cities like NYC dictate that breasts should not be visible when breastfeeding in public, or in some cases taken further to mandate that it should not be at all obvious that one is breastfeeding or even that it should not take place at all in public (11, 25-26). Even if workplaces provide a private space to breastfeed or pump breastmilk, coworkers, especially males, can portray negative reactions before or after, making breastfeeding women uncomfortable (22). Finally, these social pressures can persist even among family and friends, wherein a woman is uncomfortable when needing to breastfeed at another’s house. The influence of social norms can be so significant that a woman might stop breastfeeding to avoid social stigma, even if she feels great guilt and deprivation from the knowledge that she is potentially negatively impacting the health or enjoyment for herself and her infant (25). The fact that a threat of social sanctions outweighs the guilt over breastfeeding cessation illuminates the power of social norms and emphasizes their important place under consideration in public health interventions.

Despite its goal to lengthen the duration of breastfeeding among women giving birth at NYC hospitals, the Latch On NYC initiative failed to consider that cultural and social norms are a key factor influencing the continuation of breastfeeding beyond the hospital environment, and that currently such norms can discourage breastfeeding behaviors. The only widespread public ads included in the initiative were posters displayed in subway stops depicting the health benefits of breast milk versus formula (4). Such ads focus on education and do not address the cultural norms of breastfeeding in NYC. A well-rounded campaign that incorporates media components aimed at shifting cultural norms of breastfeeding would have a much greater chance of success in achieving its goals.

Proposed Intervention

            If a different US city aimed to achieve goals of increased breastfeeding prevalence and duration, they could certainly learn from the shortcomings of the Latch On NYC program to develop a similar intervention but one with a much greater likelihood of achieving successful outcomes. My proposal for such an intervention would incorporate several key strategies. First, to avert psychological reactance, the initiative would have a visible female leader and would emphasize the goal of supporting breastfeeding mothers, while simultaneously limiting the impression of being an anti-formula initiative (29). The initiative would still incorporate a call-to-action for hospitals, but it would ask them to pledge to help breastfeeding women by upholding state regulations to support women seeking exclusive breastfeeding, unless medically indicated and recorded in the medical chart (a statement that does not explicitly mention formula at all). A hospital-based education component for mothers undergoing prenatal and postnatal care would still be vital to provide these women with the information they need to succeed. In addition, to address the perception of workplace barriers to control of breastfeeding action, the revised initiative would include a call-to-action to employers (21-23). This would ask employers to also pledge to help breastfeeding women, by providing private and clean rooms for breastfeeding or pumping and by accommodating women with the time to take at least two 20-minute breaks for breastfeeding or pumping within a workday. Taken one step further, the workplace component could also create a Baby-Friendly Workplace recognition system that awards employers with gold, silver, or bronze qualifications based on a variety of breastfeeding-promoting benefits such as compensated maternity and/or paternity leave, lengths of job-protected leave available, accommodations such as part-time, flexible, or work-from-home hours, and physical facilities and time allotted for breastfeeding or pumping breaks. This system would provide clear recognition for businesses that excel in these categories and motivation to improve benefits and the workplace environment. Finally, to begin to influence the cultural norms surrounding breastfeeding, the advertising campaign would focus less on the health benefits and more on ways to shift cultural perceptions of where breastfeeding can take place. For example, ads would use visual images of breastfeeding women and statements such as: “You have decided to breastfeed your baby, and these city employers will support you along the way,” or “You have decided to breastfeed your baby, and you are free to do so in all city-owned public parks and facilities.” Social media strategies and partnerships with so-called “lactivists” would help to further shift cultural norms through mass gatherings of breastfeeding women in public spaces to focus media and public attention on the issue of breastfeeding acceptance and norms (32).

Defense #1: Proposal would Limit Perceived Threat to a Woman’s Choice

The described proposed intervention would use similarity to limit psychological reactance and framing to focus the issue so as to limit the perceived threat to a woman’s freedom of choice over whether or not to breastfeed (29, 33). This would represent a marked improvement over the Latch On NYC initiative, which instigated an outcry that was completely predictable according to Brehm’s theory on the reaction to a threat or elimination of choice (6). Brehm described how reactance could be mitigated through compelling justification or legitimacy (6). Silvia emphasized the potential for similarity as a tool to create legitimacy and thereby mitigate reactance (29). The lack of similarity was plain and apparent in the Latch On NYC campaign, but the proposed use of a female advocate, especially one who does not appear self-righteous in her promotion of breastfeeding, is a simple way to make considerable strides with regards to similarity. Within the concept of similarity, Silvia describes how liking the messenger can help to improve reception of and compliance with the message (29). Here, choosing a woman who has perhaps herself struggled with breastfeeding due to issues of support would help to improve her likability and the ability of other women to relate and thus respond.

The perceived threat to freedom of choice can also be potentiated through the use of framing tactics (33). Framing represents a powerful mechanism to highlight how a proposed behavior aligns with strong core values (33, 34). The Latch On NYC initiative created trouble when it described placing limits on formula distribution, which directly relays a threat to a woman’s infant feeding options and control (4, 7). Careful initiative wording and promotional materials would ensure that the intervention is described less as a breastfeeding-vs.-formula battle and more as a women’s rights and breastfeeding support initiative. An increased emphasis of the educational component provided by hospitals and lactation consultants to educate and assist women with the initiation and continuation of breastfeeding will provide further framing of the initiative as one that will help mothers to achieve control rather than limit their choices. This aligns with the views of Gallagher et al., who describe positive and gain-framed messages as having a much greater likelihood for success at impacting attitudes and behavior (34), especially for preventative health behaviors. Taken together, these components of the proposal would reduce the perceived threat to a woman’s freedom of choice over whether or not to breastfeed.

Defense #2: Proposal would Address Perceived Workplace Barriers to Control of Breastfeeding Action

Through its substantial efforts emphasizing the workplace environment as well as the hospital environment, the proposal would tackle the issue of perceived barriers to control of breastfeeding action, as employment and workplace factors represent a significant unaddressed barrier cited by many women (11, 21-23). Simply vocalizing the issue of workplace practices in support of breastfeeding may help companies to come forward and may help women to feel more confident in facing the obstacles associated with returning to work after a maternity leave and trying to maintain breastfeeding. According to the TPB, this could feed into the element of perceived behavioral control by increasing the amount of power an individual believes she has to overcome such barriers to action (17). It has been shown that supportive breastfeeding education, especially focused on strategies for maintaining breastfeeding after returning to work, can help to improve a woman’s perceived control over such situations (22).

In addition to giving women have an increased sense of power over the situation, the Baby-Friendly Workplace recognition system could motivate companies to actually change and improve the real workplace barriers to breastfeeding, such as allowing appropriate time and space for women to breastfeed or pump breastmilk while at work and providing improved maternity and paternity leave policies or flexible work options. Improving the length or compensation of job-protected leave has been definitively identified to improve the rates of sustained breastfeeding at key timepoints, such as the 6 months recommended by WHO (2, 23). Making concrete improvements to at-work facilities would also further improve the perceived control of continuing breastfeeding after returning to work (17). These measures would help to create changes in a key environment that women often cite as being a barrier to achieving continued breastfeeding for the recommended durations (11, 22) and would address the perceived workplace barriers to control of breastfeeding action (35).

Defense #3: Proposal would Start to Shift Cultural Norms Regarding Breastfeeding

By embracing an advertising focus on a topic other than the health benefits of breastfeeding and partnering with social media strategists to promote the awareness of breastfeeding in public, the proposal includes components that start to shift the prevailing cultural norms surrounding breastfeeding (1, 11, 25-26). This is in recognition of the fact that social pressures are strong and can outweigh inner pressures of guilt or regret (25). Interventions that try to address cultural norms also have an advantage in that they seek to change the actions and behaviors of many people at the same time, rather than focusing one-by-one on individuals, and so they could potentially create change much more rapidly by encouraging people to “follow the herd” (28). Media and advertising can be used to accomplish such goals of influencing social norms (24), and the ads included in the proposed initiative try to achieve this by focusing less on health beliefs of breastfeeding and more on the normalcy of breastfeeding in public. Breastfeeding activists, or so-called “lactivists,” embrace the importance of social norms and try to shift cultural views by using public displays of breastfeeding, and such group events or “nurse-ins” have been carried out in the US and abroad (27, 31-32). In recognition of the potential impact of such events, the proposal includes plans to partner with lactivists using such staged group events or social media to shift the cultural norms. Taken together, these strategies try to combat the issue of social norms regarding breastfeeding and give the proposed initiative much stronger footing compared to the NYC initiative.

Conclusions:

Upon careful examination, the Latch On NYC campaign was shown to have critical flaws in that it failed to consider the psychological reactance to a perceived threat to a woman’s choice, the perceived and actual workplace barriers to a woman’s control of breastfeeding success, and the cultural norms surrounding breastfeeding in NYC. Although these flaws limit the potential for success for this initiative, they illuminate the possibilities for improvement in a redesigned health intervention proposal designed with the same goal: to increase the rates, exclusivity, and duration of successful breastfeeding. The redesigned intervention uses similarity and framing to mitigate the perceived threat of control, awareness and motivation to promote changes in workplace barriers to breastfeeding, and advertising and public activism to shift the cultural norms.  By addressing the shortcomings and failed assumptions of the flawed intervention, the redesigned proposal has a much greater chance to affect change in US breastfeeding practices.

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