Breastfeeding as a Public Health Issue: Planning Promotional Campaigns

Breastfeeding as a Public Health Issue: Planning Promotional Campaigns Ted Greiner La 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.

Brazilian video The Components • Promotion • Use of face to face and mass media communication channels to change perceived norms

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

Breastfeeding as a Public Health Issue: Planning Promotional Campaigns