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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

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Breastfeeding as a public health issue planning promotional campaigns l.jpg

Breastfeeding as a Public Health Issue: Planning Promotional Campaigns

Ted Greiner

La Leche League Conference, Washington DC, July 3, 2005

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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

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The Components

  • Protection

    • (Making the price of reducing breastfeeding higher than the money companies can make doing so)

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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.

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Brazilian video

The Components

  • Promotion

    • Use of face to face and mass media communication channels to change perceived norms

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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)

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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

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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

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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

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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”

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Why don’t mothers breastfeed exclusively? breastfeeding

  • 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

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Why don’t mothers breastfeed exclusively? breastfeeding

  • Lack of lactation management/breastfeeding counseling

  • Lack of confidence (confidence likely to increase as knowledge increases)

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Lack of knowledge breastfeeding

  • 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.

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Time with the baby breastfeeding

  • 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

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Support for doing it right breastfeeding

  • 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

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Relation between breastfeedingsupport 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)

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Lack of confidence breastfeeding

  • 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)

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BF promotion methods breastfeedingof 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

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Professional support breastfeeding

  • 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

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Mass media and breastfeedingsocial marketing

  • Comprehensive, multifaceted

  • Variety of audiences (important to segment)

  • Evidence of impact:

    • improves attitudes

    • Increases initiation rates and possibly duration

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Countermarketing breastfeedingand 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

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Professional education breastfeeding

  • 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

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Public acceptance breastfeeding

  • Legislation ensuring the right to breastfeed

  • Support to public breastfeeding

  • Including breastfeeding in school curricula

  • Too little research to know about effectiveness

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Provision of information breastfeeding

  • 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

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Peer counseling breastfeeding

  • 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”

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Norms* breastfeeding

  • 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.

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Moderators in the influence of descriptive norms, I breastfeeding

  • 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

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Moderators in the influence of descriptive norms, II breastfeeding

  • 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)

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Who’s against breastfeedingbreastfeeding 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

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From the baby’s point of view breastfeeding

  • 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

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Recommendations for breastfeeding promotion campaigns, I breastfeeding

  • 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)

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Recommendations for breastfeeding promotion campaigns, II breastfeeding

  • Texas Dept of health MediaWatch Campaign (

  • 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

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Recommendations for breastfeeding promotion campaigns, III breastfeeding

  • 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