Babies Are Born To Be Breastfed: A Critical Review-Geetika Kalloo
Breastfeeding is a beneficial practice for both mothers and infants and has been the focus of several recent public health interventions. The focus of this critique are two advertisements released by the Department of Health and Human Services’ in their National Women’s Health breastfeeding campaign. The first featured two pregnant women who are competing in a log rolling tournament. Viewers watch as one of the pregnant women displaces the other, sending her plummeting into the water. The final shot of the women is with one woman celebrating her victory and the other being pulled out of the water in apparent dismay at her loss (http://www.youtube.com/watch?v=wC1RAr52xFo). The second advertisement is equally inappropriate. It features a pregnant woman at a “Ladies Night” in a rodeo bar. She is helped onto a mechanical bull by other pregnant women. She rides the bull with apparent glee for several seconds before she is thrown off. She jumps back up a big smile on her face (http://www.youtube.com/watch?v=WM8NLxCXlp0&NR=1&feature =endscreen). Both of the advertisements have the same voiceover and visual word prompts. They first question in words after the initial shot of the pregnant women participating in risky behaviors: “You wouldn’t take these risks before your baby was born. Why start after? Breast feed exclusively for 6 months.” It then follows with a voiceover message which states “Babies who are breastfed were less likely to develop ear infections, respiratory illness, and diarrhea. Babies were born to be breastfed!” [2, 3]
It is generally acknowledged that breastfeeding is one of the most complete forms of nutrition for infants, breast milk provides many benefits to infants’ health, immune system, and development. Breastfeeding is inimitable source of food for a baby, and though many formulas have attempted to copy its nutritional qualities none have been completely successful. Many studies have demonstrated that breastfed children have increased immunity against disease and infection in their early childhood when compared to children who are formula fed. They are also less likely to contract a variety of diseases later in life, including juvenile diabetes, multiple sclerosis, heart disease, and cancer.
Additionally, breastfeeding is also beneficial for the mother. Women who breastfeed have a decreased chance of developing osteoporosis later in life, have lower risks of breast, uterine, and ovarian cancer, and are able to lose weight gained during pregnancy with greater ease. Breastfeeding can also serve as a cost cutting method for young families. It is considerably more cost effective than buying formula. It also avoids medical bills associated with early childhood illnesses that infants are at greater risk for if they are formula fed. Therefore, the goal of the Women’s Health campaign is well intentioned, but the campaign itself fails to effectively inform the viewer of any of the above mentioned benefits and risks. In fact the only emotions that the two advertisements manage to incite in viewers are of disgust and ridicule.
These two advertisements fail to properly address any of the benefits associated with breastfeeding. Rather they rely instead on ludicrous imagery which fails to serve any purpose. The predominant fault of this campaign is that it misapplies or utilizes outdated multiple public health theories. In analyzing these two advertisements it is clear that the Department of Health and Human Services has attempted to utilize the Health Belief Model, Theory of Reasoned Action and Social Expectations Theory. All three are well established models of public health change. However, the manner in which they are applied is not conducive with the subject matter at hand and therefore the campaign is ineffective. In order to better elucidate the flaws of the intervention an in depth review of this breastfeeding campaign is warranted.
Critique Argument 1- The Health Belief Model
The first fault of the Woman’s Health campaign is its use of the Health Belief Model (HBM). The HBM is a psychological model which attempts to predict behaviors related to health. The underlying theory of this model states that individuals make decisions after taking time to understand the perceived costs and perceived benefits of the health behavior, in this scenario breastfeeding. The implications of the perceived benefits or harms are determined by how susceptible the target audience believes they are to the dangers outlined, and how severe they think the repercussion of the “incorrect” action would be. This model believes that individuals weigh both sides of the issue and come to a rational conclusion regarding the health behavior with the best outcome.
Firstly, this campaign fails to correctly utilize the HBM. In order for the viewer to ascertain the perceived harms and perceived benefits of breastfeeding, they must be provided with complete and accurate information about the behavior. Both advertisements provide limited information about the benefits of breast milk. In fact they simply state a reduced risk of three minor ailments, whereas the benefits of the breastfeeding are far greater than these paltry reasons. Furthermore, viewers are provided with no actual perceived risks. In order for the HBM to work most effectively complete information about breastfeeding must be presented to the viewers. Without this mothers will be unable to fully weigh the perceived benefits and harms of the behavior. 
The creators of this campaign rely on the ridiculous scenarios in order to present the perceived risks associated with not providing a child with breast milk. They attempt to liken the harms of not breastfeeding with a pregnant woman being thrown of a mechanical bull or almost drowning. The fact of the matter is that the majority of woman formula feed their child at some point. In fact a study found that only 45% of infants were exclusively breastfed one week after being born. Therefore, individuals know from the experience of others that not providing breast milk does not have the same dangers as a serious accident during pregnancy. Thus most individuals who view this commercial would discredit the entire campaign because it does not provide a sufficient number of perceived benefits and unrealistic perceived harms. The HBM is completely knowledge based, and seeks to provide information to individuals in order for them to assess their situation and make an appropriate decision. But the implications regarding breastfeeding in this campaign are blatantly false and thus it is unsuccessful in part because the model is misapplied. They fail offer accurate information for mothers to utilize in making this decision.
If this campaign had more accurately used HBM, it would still fail to effectively convey its message. HBM is not a suitable model for an intervention regarding breastfeeding. It is an individual based model and stresses personal responsibility for health behavior. These commercials rely on the fact that it up to the woman to choose to breastfeed her child. This may lead people to feel it is they “fault” if they cannot are not capable of completing the action. Yet some women have to go back to work or are unable to produce breast milk, which are not factors that they have any control over. These advertisements would alienate rather than inform those individuals and make the campaign less successful. Furthermore, HBM based interventions have been shown to work less effectively with decisions that are taken daily such as smoking, eating nutritiously, and exercising. Breastfeeding can be counted among these daily decisions as mothers can switch to formula at any point should it become too inconvenient to provide milk themselves. HBM assumes that what a person values and beliefs are static from one day to another. There is a complexity in making day to day decisions that is not accounted for in the HBM. A mother might provide milk for her child while she’s on maternity leave but once she gets back to work, her priorities and perceived benefits and harms regarding the situation change. The information provided in this campaign using the HBM is not sufficient to persuade women continue with this positive health behavior.
Critique Argument 2-Theory of Reasoned Action
The use of the Theory of Reasoned Action (TRA) in this intervention demonstrates that the creators believe that all individuals are rational and their behavior is determined by their intention to breastfeed. The TRA suggests that an individual’s behavior is determined by his intention to complete that behavior. Intention is defined as an individual’s readiness to perform a given health related action. An individual’s intention to complete an action is based on their attitudes towards that behavior, in our case breast feeding, as well as their perception of subjective norms associated with that activity. Attitude in this scenario is derived from the sum and evaluation of an individual’s beliefs about breastfeeding. Subjective norms can be better understood as “the person's perception that most people who are important to him or her think he should or should not perform the behavior in question.” The TRA component of this intervention is the explanation of positive outcomes for a child’s health to influence the attitudes of new mothers towards breastfeeding. They also attempt to use the mechanical bull riding and log rolling to demonstrate the subjective norms associated with formula feeding one’s child, in order to influence a woman’s intention to breastfeed her child.
As mentioned with the HBM critique this campaign fails to effectively provide many benefits or outline the harms associated with choosing to breast feed or formula feed. Therefore, TRA is not being properly utilized to influence the attitudes of the target audience or change how they view the subjective norms associated with this action. The campaign attempts to provide three potential health benefits to a child in comparison to a horrible accident to a pregnant woman. They expect women to evaluate the benefits and harms between the two scenarios. These advertisements may influence a woman’s attitude associated with log rolling during pregnancy or riding a mechanical bull, but the comparison is so ludicrous that it certainly will not change her attitude or influence her belief about how society views breastfeeding. Therefore this campaign fails to use TRA in order to change the intention of would-be mothers to breastfeed.
Furthermore, the use of the TRA in this particular scenario is flawed. “The aim of the TRA is to explain volitional behaviors. Its explanatory scope excludes a wide range of behaviors such as those that are spontaneous, impulsive, habitual, the result of cravings, or simply scripted or mindless. Such behaviors are excluded because their performance might not be voluntary or because engaging in the behaviors might not involve a conscious decision on the part of the actor." Behaviors such as breastfeeding, which are habitual, do not fare well when targeted by a static model like the TRA because these decisions are not influenced by the same attitudes or subjective norms on a daily basis. It has also been shown that when a choice between alternatives exists, breastfeeding versus formula feeding, TRA functions much less effectively in creating intention. TRA functions best in a yes or no decision. Therefore the TRA is not an appropriate mechanism to create the desired change in regards to breastfeeding.
Critique Reason 3- Misapplication of Social Expectation
This campaign relies most heavily on the Theory of Social Expectations. This paradigm relies on the fact that individuals’ behavior is dictated by social norms. Social norms are defined as the behavior patterns and expectation that people observe in the environment around them. Individuals comply with these behavioral patterns and beliefs without consciously engaging in them. In fact it has been "long argued that people tend to adopt group attitudes and act in accordance with group expectations and behaviors based on affiliation needs and social comparison processes, social pressure toward group conformity, and the formation and acquisition of reference group norms." This implies that individuals generally prefer to conform to expectations of society rather than confront them. This is true regardless of whether these actions are concurrent with their belief systems, because most people place a high value on acceptance from their peers and society. Attitudes of groups can be changed en masse with first changing the behavior of the group and their beliefs regarding the action should follow suit.
The Women’s Health campaign relies heavily on social expectations and norms surrounding motherhood. It appeals to the desire of women to be viewed as good mothers by society. As mentioned previously, the implications of the advertisements are that formula feeding your child is akin to log rolling or riding a mechanical bull whilst pregnant. The shock value of both these scenarios also attempts to elicit a reaction about the deviation from social norms. The commercials make it clear that it is not socially acceptable to participate in these risky behaviors during pregnancy. The intervention then attempts to draw a parallel between the disapproval that a woman would receive if she participated in these activities during pregnancy and if she chose to not breastfeed her child.
Social Expectations Theory is a perfectly legitimate model to use in case of a breastfeeding intervention. It is very likely that if women believed that society expected all mothers to breastfeed, we would see an increase the number of infants who exclusively given breast milk for the first 6 months of their lives. Unfortunately, this particular campaign blatantly misapplies this model. There is no doubt that the imagery in these advertisements will cause shock amongst the viewer. But because formula feeding is so common in society, women are fully aware that the social implications of not breast feeding one’s child are not as severe as those for willingly participating in the behaviors shown in these advertisements. In fact the stories presented in the Women’s Health Campaign only manage to reaffirm the societal condemnation regarding risky behavior and pregnancy. It fails to draw a parallel between those actions and breastfeeding. The social expectations paradigm is not at work within this campaign and only serves to add to the ludicrous nature of the commercial. Therefore their attempt at using Social Expectations Theory further adds to the ineffectiveness of this campaign.