Challenging Dogma - Fall 2011

Saturday, December 24, 2011

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.[1] 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 ([2] 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 ( =endscreen).[3] 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.[4] 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.[5]

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.[6] 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.[7] 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.[8]

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. [8]

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.[9] 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.[10] 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.[7] 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.[11] 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.[12] 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.”[13] 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."[14] 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.[15] 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."[16] 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.[17]

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.

Proposed Intervention

The goals of this campaign are quite noble and would benefit society greatly. In fact “widespread recommendations from health organizations encourage exclusive breastfeeding for six months.”[18] The Women’s Health Campaign would have been much more effective had they used different models to deliver their message. Therefore, the proposed intervention is a complete overhaul of the campaign presented by the Department of Health and Human Services. The goal behind the proposed intervention in to create change utilizing the irrational aspects of human nature, which studies have shown create greater change than those which are based on facts and statistics. This intervention is attempting to make group level change in behavior that will ultimately impact and change the attitudes that individuals have towards breastfeeding. This campaign will also be reliant of a series of commercials much like the Women’s Health intervention in order to reach the largest number of people. We will attempt to correctly apply Social Expectations Theory as well use Advertising Theory, Optimistic Bias and the Law of Small Numbers in order to produce the most effective campaign strategy. The target audience of this intervention are all women who are about become mothers and are physically capable of breastfeeding. My intervention techniques will positively enforce breastfeeding using stories that women can relate to and techniques that lead them to believe that breastfeeding is an expectation from all mothers.

Intervention 1- Proper Application of Social Expectation Theory

As mentioned in its critique Social Expectation Theory functions under the belief that norms outlined by society are the basis of how individuals determine what behavior is expected and acceptable in the environment in which they live. Social Expectations theory is a group level model which means that it attempts to make change by facilitating action amongst peer groups. Individuals can observe others in their environment participating in the positive behavior and follow suit whether or not their attitudes coincide with the actions they are taking.[17] Social expectations theory has been shown to be effective in several public health campaigns such as the use the seat belts in cars and the ban of smoking in Massachusetts bars and restaurants.[19]

In order to best use the Social Expectations paradigm with regards to breastfeeding we would focus on the positive health behavior that is expected of new mothers. Thus, rather than focusing on the disapproval one would receive for formula feeding their infant, the new campaign would focus on the respect and accolades one would receive for exclusively breastfeeding their child for six months. Our campaign would also emphasize the fact that the majority of mothers breastfeed with success, increasing the new mothers’ confidence that they could also complete this behavior.

The first series of advertisements of the new breastfeeding campaign would feature a variety of women from all different socioeconomic demographics breastfeeding children ranging from one to twelve months of age. Using a variety of women from different social demographic groups would emphasize the fact that individuals from all walks of life participate in this behavior. Enforcing the belief that breastfeeding is not specific to any particular group. We would show these actions occurring in a variety of “normal” places including at home, work, a park and other public places. The imagery would bring to light the fact it is easy and acceptable by society to breastfeed anywhere. All other individuals in the advertisement, who are present around the breastfeeding women, would have “Breastfed for X months” written on their shirts. The X would represent the number of months that the individual was supposedly breastfed. This would confirm that not only is it socially acceptable for new mothers to breastfeed but that also the majority of children are breastfed. Therefore utilizing the Social Expectations Theory in our campaign would encourage new mothers to believe that breastfeeding was the norm and increase the number of women who participate in this beneficial practice.

Intervention 2- Advertising Theory

Employing Advertising Theory to promote breastfeeding would significantly increase the effectiveness of the campaign. Advertising theory in public health implements the methods used by companies to sell products in endorsing positive health behaviors.[20, 21] Advertising theory uses print or TV media to tell a story with a promise of a positive health outcome and provide support, or evidence, for that promise. Both the promise and support are depicted through the imagery, dialogue or music in the advertisement, and attempt to elicit a response from the viewer based on their core values.[22] Core values can be defined as the deepest aspirations that individuals have, such as love, freedom, and independence etc. In the case of new mothers the proposed campaign will capitalize on the core value of maternal love and a mother’s desire to protect and nurture her child.[23]

Adoption of the Advertising theory is a more effective method of promoting breastfeeding than use of the Theory of Reasoned Action. The TRA believes that individuals behave in rational manner after weighing their personal beliefs and those of society, which has been demonstrated as an unsuccessful means of creating change in breastfeeding behavior. Advertising theory on the other hand capitalizes on the irrationality of individuals and the importance they place on their core values to effectively persuade them participate in positive health behaviors.[22] Unlike the TRA advertising theory does not rely on facts or statistics which are easy to disregard, but rather focuses on positive emotions to make promises that are easily relatable for the majority of people.[20]

The proposed campaign would also produce an advertisement in which mothers would we shown breast feeding their infants. The next shot would show the same woman twenty to thirty years later standing next to her son or daughter who in now the President of the United States, a famous scientist, or professional athlete etc. The promise of this campaign is that the benefits of breastfeeding are long reaching and promote development of the child so that they can grow up to accomplish great things. The support in these advertisements is provided the images of the aged mother standing next to her famous and successful child. The advertisement will be accompanied by a song that focuses on the beauty of the relationship between a mother and her child. This will emphasize the core value that is being expressed in the advertisement of maternal love. This commercial will provide essentially the same reasoning for breastfeeding as the Women’s Health campaign attempted with the use of the TRA, but this is more effective. Rather than stating bland facts, the new advertisement demonstrates the benefits of breast milk through compelling visual imagery. The use of advertising to convey a story, that takes advantage of core values and emotions of the audience, will lead to effective change in the perception of breastfeeding. This should result in an increased number of women participating in this positive health behavior.

Intervention 3- Utilizing Optimistic Bias and Law of Small Numbers

The final psychological models that the proposed campaign would utilize are the Optimistic Bias and the Law of Small Numbers. Optimistic bias theory states that when individuals are given facts and statistics about potential health risks they tend to believe that others fall within the risk but they are unlikely to be susceptible.[24] People generally over estimate the likelihood of positive outcomes and under estimate the chance of negative events. So individuals who are told that their children are at higher risk of disease if they are not breastfed are likely to consider this information more likely to be true for their peers rather than themselves.[25] Therefore, the information provided in the Women’s Health Campaign would be easily discredited by the viewer because they do not believe that they are susceptible to the harms outlined. Furthermore, the Law of Small Numbers explains that individuals are far more likely to believe a story told by one or a small group of individuals sharing personal experiences rather than a plethora of confusing statistics.[26]

The HBM provides facts and figures that attempt to explain the benefits and harms associated with breastfeeding. According to the Law of Small Numbers and the Optimistic Bias this method is ineffective in conveying information. Rather, it would be beneficial to provide an example of one woman who told her personal story regarding the positive impact that breastfeeding had on her child.[27] With this method it is possible to relay the same or even greater number of facts than presented in the Women’s Health campaign.

The new campaign would feature advertisements in which real mothers who had breastfed their children gave testimony to the fact that their children were far healthier than children who had been formula fed. Providing specific details about their experiences would make the stories seem more realistic and relatable for the target audience. This would in turn increase the validity of the advertisement. Utilizing a personal story, as suggested by the Law of Small Numbers, rather miscellaneous facts and statistics allows us to provide an increased amount of accurate information. Furthermore, this information is presented in a more appealing, relatable and effectual manner, and thus should persuade a greater number of women to breastfeed.


The new intervention is complete change from the campaign put forth by the Department of Health and Human Services. The proposed intervention attempts to make group level change utilizing Social Expectation Theory, Advertising Theory, and an understanding of the Optimistic Bias and Law of Small Numbers. Using these models allows us to put forth a campaign that is relatable and emotionally appealing for all women. It also emphasizes breastfeeding as a societal norm. Unlike the Women’s Health Campaign, our intervention does not rely on scare tactics, as those have been shown to be generally ineffective. This intervention attempts to modify behavior at the societal level, with an understanding that attitudes regarding breastfeeding will change as the practice becomes a usual occurrence amongst women.


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2. Department of Health and Human Services. Ad Council Breastfeeding PSA. National Women's Health Breastfeeding Campaign 2003 [cited; Available from:

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6. NRDC. Healthy Milk, Healthy Baby, National Resources Defense Coucil, Editor. 2005: New York City.

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14. J.L. Hale, B.J.H., K.L. Greene, The Theory of Reasoned Action. , in The Presuasion Handbook: Developments in Theory and Practice, M.P. J.P. Dillard, Editor. 2003, Sage: Thousand Oaks. p. 259-286.

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18. G.E. Becker, S.R., T. Remmington, Early Additional Foods and Fluids for Healthy Breastfed Full Term Infants in The Cochrane Collaboration. 2011, Cochrane Pregnancy and Childbirth Group.

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20. W. Leiss, S.K., S. Jhally, Social Communications in Advertising: Person, Products and Images of Well-Being. 1990, New York Routledge

21. Lupton, D., Consumerism, Commodity Culture and Health Promotion. Health Promotion International 1994. 9(2): p. 111-118.

22. Steven M. Kates, C.G., Brand Morphing: Implications for Advertising Theory and Practice Journal of Advertising 2003. 32(1): p. 59-68.

23. Seigel, M., Advertising Theory, I.C. Lecture, Editor. 2011: Boston University.

24. Weinstein, N.D., Unrealistic Optimism About Future Life Events Journal of Personality and Social Psychology 1980. 39(5): p. 806-820.

25. D. Dunning, C.H., J.M. SUls Flawed Self-Assessment. Implications for Health, Education, and the Workplace. Psychological Science in the Public Interest, 2004. 5(3): p. 69-106.

26. Rabin, M., Inference By Believers in the Law of Small Numbers. The Quarterly Journal of Economics, 2002. 117(3): p. 775-816.

27. G. Quattrone, E.E.J., The Preception of Variablity Within In-Groups and Out-groups: Implications for the Law of Small Numbers. Journal of Personality and Social Psychology, 1980. 38(36): p. 141-152.

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