Issue 18: Talking about breastfeeding: Why the health argument isn't enough

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May 1, 2010

In 2007, paparazzi snapped photos of Maggie Gyllenhaal breastfeeding her daughter in public. The photos flooded the Internet and Gyllenhaal was labeled a feminist superhero.1 In 2008, W Magazine splashed a breastfeeding Angelina Jolie across its front cover. The smiling Jolie was called "beautiful," "natural" and "peaceful."2 Both women gave a heavy dose of celebrity to what the American Academy of Pediatrics, the U.S. Department of Health and Human Services and others in public health have been telling mothers for years: Breast milk is best.

The message, backed by studies linking breastfeeding to health benefits both for the baby (e.g. higher IQs, lower obesity rates, protection against heart disease) and the mother (e.g. decreased risks of osteoporosis, breast and ovarian cancers, and type-2 diabetes), sounds simple enough. But for many women, breastfeeding is not so easy. A searing article by Hanna Rosin3, published in 2009 in the Atlantic, made palpable this reality, raising the profile of the breast milk-formula debate and putting public health advocates in the hot seat: Were the health benefits of breastfeeding as proven as popular literature suggested? Was breastfeeding a realistic option for all mothers? Rosin, mother of three, was skeptical. So she researched — and soul-searched — and the mother in her conceded that, for the baby's health, "yes, breast is probably best." But to questions outside of health, the woman in her said "no." For Rosin, breastfeeding was not just a matter of science, nor was it the stuff of celebrity bliss. It was a strain. And after 28 months of it, she described it as a prison.

Rosin is not alone in her experience. Nationally, less than 12 percent of women breastfeed exclusively, giving their children no solid foods and no liquids other than breast milk for a full six months4, as organizations such as the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and World Health Organization recommend. Although the majority of women start out wishing to breastfeed — in California, nearly 87 percent of new mothers initiate breastfeeding5 — something happens along the way that discourages more than half of them from continuing to breastfeed exclusively.

Too often, that discouragement begins in the hospital, where outdated policies, insufficient support and routine practices such as separating the mother from the baby and handing out free formula samples can undermine a mother's best efforts to breastfeed. By the time they leave the hospital, only 43 percent of California mothers are still breastfeeding exclusively, and that number continues to drop as women encounter more obstacles outside of the hospital.6

A lack of cultural support can make breastfeeding in public embarrassing and impractical. A lack of workplace support can put breastfeeding at odds with a woman's job. For example, policies requiring paid maternal leave and on-site lactation rooms for returning mothers often go unenforced, particularly among low-wage-earning women — the very population that already experiences health disparities and stands to benefit the most from breastfeeding. On top of these hurdles, breastfeeding can be painful and time-consuming because, unlike bottle-feeding, it requires the mother to be present. Rosin's article gives voice to the many women who want to breastfeed but have found its barriers too high, too exhausting. It also gives public health advocates an impetus to analyze public conversations and attitudes about breastfeeding and evaluate to what extent their own messages are successful in focusing on the policies needed to remove the obstacles that keep women from breastfeeding.

To that end, the California WIC Association approached Berkeley Media Studies Group for help with analyzing its materials on breastfeeding, paying particular attention to CWA's reports on breastfeeding rates in various hospitals and regions throughout the state and the news coverage they had generated. Because women who exclusively breastfeed in the hospital are more likely to exclusively breastfeed at home, one of CWA's objectives is to improve the policies surrounding the education and support that hospitals give to mothers with newborns. CWA would like to see all delivery hospitals and birth centers in California either adopt "model hospital" policies — those recommended by the California Department of Public Health for meeting state and national breastfeeding goals — or become certified as "Baby-Friendly" — an international designation with detailed guidelines for achieving the same goals. Although California boasts more Baby-Friendly hospitals than any other state, as of 2007, there were only 187 out of more than 250 hospitals, about 7 percent. By 2009 there were 26.8 To help bring that number up, CWA has added a robust arm to its media advocacy strategy that focuses specifically on medical professionals, hospital administrators and other community decision makers, outlining actions they can take to increase exclusive breastfeeding rates and subsequently reduce health disparities. CWA wanted to know: How have those reports been characterized in the news?

Why framing matters

California WIC Association's messages, no matter how carefully crafted, are not delivered in a vacuum. They can be picked up and amplified — or distorted — in the media; they can end up reaching a different audience than the one intended; and, ultimately, their meaning comes as much from the person receiving the message as from the person sending it. That's because the starting point for any communication isn't just the words or pictures presented to people but what people bring with them from prior understanding, experience, and their culture. These prior notions are called frames.

Frames are mental structures we use to integrate new information into our brains in a coherent way. New information — whether a word, image, or action — triggers concepts already familiar to us. These concepts, once activated, make this new information meaningful by evoking associations, emotions and responses to everyday information. Since people can hold multiple, even contradictory, frames in their heads at the same time, the one that gets triggered and repeated more often has a better chance of influencing people's interpretation of the text.

In news coverage, the frame is the way an issue is defined, packaged, and presented in the story. When covering stories, journalists select certain arguments, examples, images, messages, and sources to create a picture of the issue. This selection — or omission — of arguments and voices not only indicates to readers what is important about an issue, but also what is not. In so doing, reporters signal what or who is credible, which positions and arguments are valid, and which aspects of an issue need not even be considered. Like a frame around a painting, the news frame draws attention to a specific picture and separates told from untold pieces of the story: Elements in the story are said to be in the frame; elements left out of the story are outside the frame.

Frames are powerful because they foster certain interpretations and hinder others, often without a person's awareness. For example, most news frames focus on individuals or events which prompt interpretations that emphasize personal responsibility to the exclusion of other factors.9 News media tend to frame stories episodically, more like portraits than landscapes that can bring the context into view.

Frames can also act in the background to affect, for example, whether we see breastfeeding as something normal or deviant; healthy or unnecessary; admirable or offensive. They influence whether we see a woman's breasts as delivery systems for food or symbols for sex (after all, if breasts weren't highly sexualized in our popular culture, why would some women feel embarrassed about breastfeeding in public?).

Understanding how an issue is framed can help advocates anticipate what people think about the issue, and what they'll need to do to help people see the issue differently. This is especially important when policies are being considered. If the policy advocates seek falls outside the frame, it will be hard for people to understand why the policy is necessary.

What we did

To discover what frames are operating in public conversations about breastfeeding and how those frames relate to the California WIC Association's efforts to shape hospital policies on this issue, Berkeley Media Studies Group analyzed a variety of materials provided to us by CWA on its key media advocacy actions. These included documents produced by CWA, select academic literature on breastfeeding, selected California news coverage of breastfeeding, including CWA's policy initiative on Baby-Friendly hospitals, and recent high-profile national news coverage of breastfeeding more generally. The materials we examined were published from 2006 through 2009.

The selection of these documents means that the sample BMSG analyzed had certain constraints. As a result, this analysis provides only a partial perspective, not a complete overview, of CWA's efforts to reframe and achieve policy successes on breastfeeding policy.

Cognitive linguist Pamela Morgan, PhD, worked with BMSG in an iterative process to determine the frames at work in these policy and media pieces. In this Issue, we summarize Dr. Morgan's findings, apply them to our reading of the CWA news coverage, and consider the implications for CWA's policy advocacy in the future.

Frames in the background

All of the breastfeeding materials, regardless of their source, have at least one significant thing in common: They exist against a backdrop of ideas and assumptions that people already hold about breastfeeding, as well as powerful cultural expectations about its place in society. It's difficult to think or talk about breastfeeding without cueing images of a woman and a baby. And it's nearly impossible to settle on those images in a neutral way, without connecting them to other concepts or making judgments. Those connections are what cause us to see the woman not just as a woman but as a mother. And that mother is not just a mother; she is a caregiver. She is responsible for ensuring the health and well being of the baby. Why? Because that's what our culture tells us "good mothers" do.

Along with the Good Mother, other frames in the background concern Food, Modernity, and Nature. Food is present since breastfeeding is above all a source of nourishment for infants. A Modernity frame is in the background since breastfeeding is discussed in terms of contemporary life. The Modernity frame is contrasted with Nature since breastfeeding is also a practice done by all mammals. These basic frames permeate the messages journalists and public health advocates alike send about breastfeeding, whether or not they intend those frames to be included, and whether or not the recipients of the messages are conscious of them.

We describe each frame below, beginning with the Good Mother, an essential frame for understanding the discourse around breastfeeding because all other frames relate back to it.

The Good Mother

The Good Mother is a cultural icon. She exists as a romanticized ideal. She is the woman who puts the needs of the baby before her own, raises and nurtures the baby, and ensures the baby's physical, mental and emotional health. She works hard; she never tires; she is a myth. Visions of the Good Mother may vary from person to person and generation to generation, especially as ideas about gender change, but she is deeply embedded in our culture and going nowhere soon.

Because conceptual frames work in the background, the phrase "good mother" doesn't have to be uttered for the idea to be present. The frame gets expressed in news stories this way: "Vivovich is still breastfeeding her child and plans to continue as long as she can. 'It's really hard,' Vivovich said. 'As busy as I am, I make it the No. 1 priority of my day because it's going to provide her with all the defenses of the immune systems for the rest of her life.'"10 By doing everything in her power to satisfy the needs of her baby, Vivovich personifies the Good Mother.

Even without directly mentioning women at all, the Good Mother can color the meaning of stories about breastfeeding. So, if a statement reads, "Breastfeeding is best for babies," one likely interpretation is, "Good mothers breastfeed their babies." This is how, for example, an advocate's statement about the health properties of breast milk can be interpreted as a challenge to a woman who, for whatever reason, does not breastfeed. At a subconscious level, "Breast milk is best" can be understood as "You are not a good mother unless you breastfeed."

Nature vs. Modernity: The Good Mother in the modern world

In ancient times, breast milk was the way to feed a baby. Formula is a product of modern science. And so the battle between breastfeeding advocates and formula companies is also a battle between Nature and Modernity. These frames contrast the purity of the past with the promise of the future and send conflicting messages about how the Good Mother should best care for her baby in our modern world.

Breast milk, which is aligned with the Nature frame, is prized for an almost spiritual connection with good and right: Nature is the way the world is meant to be. Nature is preferred because it is purer — marketers draw on this frame when they tout "all natural, no artificial ingredients" to attract customers. In this way, natural is better. Nothing can be more Natural than breast milk, advocates might say: "Most babies will make their way to the breast on their own within the first hour after birth. It's a natural process."11 Breastfeeding advocates evoke this frame when they criticize formula as being unnatural: "We perform a disservice to American families by perpetuating the myth that feeding human infants artificially created formula is equivalent to breastfeed ing."12 Formula companies try to get on the bandwagon by promoting "nutrients naturally found in breast milk."13

The Nature frame is in conflict with the Modernity frame, which is most closely aligned with formula. The Modernity frame posits that by applying science and reason, people will make steady progress to a more comfortable, integrated, and enlightened life. Formula companies draw on this frame when they emphasize the nutrition science from which their products derive. Formula companies also position themselves on the side of convenience, one of Modernity's biggest hallmarks.

Modernity and Nature are not always at odds, but at their extremes, they are in conflict because Modernity gives primacy to humans over nature and elevates scientific endeavors as the way to make progress. Medicine (when it succeeds) is a particular instance of the triumph of Modernity over Nature. Even when medicine doesn't succeed, the hope it promises evokes the idea of Modernity improving upon Nature. Breastfeeding advocates link to the promise of Modernity when they refer to the science behind health benefits, as in "Breastfeeding is the best way to give babies a healthy start in life. Research shows that breast milk is the best food for your newborn ..."14

Nature vs. Modernity: Exploiting the Good Mother

The Good Mother frame underlies the battle between breastfeeding advocates and formula companies vying for the hearts and minds of new mothers. This is problematic because the Good Mother frame places full responsibility for breastfeeding in the hands of the individual woman. It assumes that the ultimate decision of whether or not to breastfeed — and for how long — is the mother's when, more realistically, there is often a wide gap between what a mother wishes to provide for her baby and what she is able to provide. The Good Mother frame works against breastfeeding advocates' wider social change goals because it masks the many barriers, such as short maternity leaves or no workplace facilities for pumping and storing milk, that make it difficult for women to breastfeed. This helps explain why criticism of low breastfeeding rates or calls from breastfeeding advocates to increase those rates can raise the defenses of mothers who may interpret the criticism as a personal indictment.

The Good Mother frame works to the advantage of formula executives, who exploit this fear of being a bad mother to sell more of their product. They tout their formula as not only healthy for the baby but also convenient, affordable and pain-free for the mother. Their advertising features dubious health claims linking, for example, specific ingredients in certain formulas to improved brain development in babies. These companies work to convince people that by better living through science, women can bypass guilt, feed their babies formula and still be Good Mothers — maybe even better ones.

Nature vs. Modernity: Experts vs. Mom

Although breastfeeding advocates and formula companies are competing with each other to woo new moms, both sides frame their arguments from the perspective of an Expert. A manifestation of the Modernity frame, the Expert frame uses facts, statistics and jargon to give breast milk and formula medicalized interpretations. This is a transformation of a basic Food frame. It insists Food is not just for essential nourishment but also for providing nutrition, preventing disease, and ensuring good health.

The Expert frame also contends that mothers need to be taught how to feed their children. First, they must look to Experts to decide whether to use breast milk or formula; then they must learn the right techniques for delivering their choice of food. For breastfeeding, that might mean learning how to hold the baby and initiate the flow of milk; for formula feeding, that includes learning how to measure, mix and heat the contents of the bottle. As one lactation counselor told a reporter, "Many women think babies come here knowing how to position themselves, where to put their mouths... sometimes these babies come here with some challenges and that's where lactation9 counseling is really helpful."15

The Expert frame helps explain why, even though most people likely believe breastfeeding is a natural, biological and instinctual process, they also believe that, in many instances, women cannot do it well without instruction and support. But teaching non-experts to think of breastfeeding as an activity controlled by Experts has potential downsides. It suggests that, to make a decision between breast milk and formula, all new mothers need is more information and education about the differences between the two. With the Good Mother frame in full force, this distracts from the numerous social and cultural barriers that discourage women from breastfeeding.

Overall, the breastfeeding discourse we examined evokes the Good Mother in the context of the Modern world. The Good Mother frame is an inherently individual one. It reinforces a culture that puts a premium on personal responsibility consistent with the rugged individualism that exists almost ubiquitously in the background of most American cultural expressions. The Good Mother frame highlights the individual mother and her decision whether or not to breastfeed. This emphasis minimizes attention to or understanding of the context in which those decisions are made, be they workplaces, hospitals, or other places in society. Settings and circumstances do not enter into the Good Mother frame. The Good Mother is seen against the backdrop of Nature or Modernity, paradoxically sometimes as breastfeeding is characterized both as being natural and as requiring expertise and assistance.

Breastfeeding frames in the news

We found a continued presence of the Good Mother frame in various articles on breastfeeding appearing in the national media from 2006 through 2009, as well as Nature, Modernity and Expert frames. While the focus of the articles varied, the majority discussed breastfeeding's role — and, indirectly, the Good Mother's role — in ensuring the health of the baby and preventing disease. These frames, Breastfeeding Ensures Healthy Babies and Breastfeeding Prevents Disease, take what would be a Food frame and make it a Health frame. A smaller but notable number of articles decried the idea that the baby's health should be put before the needs of the mother, and offered a counterpoint with the frame Women Have Needs Too.

Breastfeeding Ensures Healthy Babies

The idea that Breastfeeding Ensures Healthy Babies was present in almost all the materials we examined. In this characterization of Health, Experts are the voices of authority, trumpeting the science behind the link between breastfeeding and Health, and the Good Mother tries to act on that information to meet the needs of her baby.

Breastfeeding Prevents Disease

Breastfeeding Prevents Disease, or simply, Disease Prevention, is a special case of the Health frame, which suggests that breastfeeding acts as a kind of medicine to ensure the health of the baby both now and into the future. The Disease Prevention frame is evoked each time breastfeeding is said to protect babies from medical conditions such as diabetes, as in "Children who are breast-fed are at a lower risk for a variety of issues like childhood obesity, asthma, ear infections, upper respiratory infections and certain autoimmune diseases,"16 or "Up to 30 percent of diabetes is thought to be preventable in children if they are not exposed to other feeding methods during the first three months of life."17 Though the Disease Prevention frame is most obviously linked to Modernity and Expert frames, it ultimately circles back to the Good Mother frame, which upholds the belief that personal behavior choices, such as what a mother gives her baby to eat, can help cause or prevent chronic diseases. A Good Mother would do everything to prevent disease in her child; thus a Good Mother would breastfeed.

The Good Mother and Disease Prevention frames are easily combined, as in the quote from the newspaper we saw earlier, "Vivovich is still breastfeeding her child and plans to continue as long as she can. 'It's really hard,' Vivovich said. 'As busy as I am, I make it the No. 1 priority of my day because it's going to provide her with all the defenses of the immune systems for the rest of her life.'"18 And in this quote from a different news story: "Breastfeeding should not be thought of as an option for the mother, but rather as a right of the baby, because it will guarantee the baby is healthier and has less risk of contracting illnesses, ranging from infections and chronic allergies to anemia and diabetes and obesity."19

Women Have Needs Too

The Women Have Needs Too frame includes the idea that the baby's needs should not supersede the mother's needs — that, at minimum, both sets of needs must be considered together, including a woman's career goals and ability to meet workplace demands, her psychological health, the need for privacy and physical dignity, the need to be accepted in social circles, the desire for convenience, and the need to avoid pain unless there is a good reason to accept it. The messages evoking this frame can express frustration with the idea that the baby's needs should always come first, yet they do not break free from individually oriented confines of the Good Mother frame. Expressions of this frame still contend that breastfeeding is a decision that each mother makes for herself; they simply try to expand the definition of the Good Mother to include both mothers who breastfeed and mothers who formula feed. In Hanna Rosin's Atlantic article, for example, she suggests writing down all the reasons for breastfeeding and all the reasons for using formula, tallying them and then making a decision. Even so, Rosin's article still discusses Health at length, as do other news stories that do address women's needs, reinforcing the idea that breastfeeding is about the Health needs of the baby. Even in the Rosin article, the Women Have Needs Too frame has to compete with frames that put the baby first.

An attempt to reframe

The Good Mother idea can be antagonistic to breastfeeding advocates' goals unless it is substantially reformed or reframed. For example, how would the definition of a Good Mother change in a society that supported women in a variety of roles and environments that favored breastfeeding? However, at present, while breastfeeding advocates strive to change social attitudes and norms to foster environments that value and support women, children and breastfeeding, the current Good Mother is a strictly individual construct. Breastfeeding advocates may need to reframe the Good Mother concept so that it includes the context surrounding mothers and the fact that breastfeeding requires support.

The California WIC Association's efforts to improve exclusive breastfeeding rates are an example of a specific campaign to do just that. CWA began with the understanding that improving breastfeeding rates requires creating supportive environments and decided that a good place to start is in hospitals, the place where babies are born. What troubled them was that they knew from surveys that a majority of mothers go into hospitals stating they want to breastfeed, but fewer than half come out doing so exclusively.20

So, in 2006, CWA began releasing periodic reports exposing disparities in breastfeeding rates in hospitals throughout California. The target of the reports was not new mothers — these were not educational or instructional pieces. Instead, the target was hospital administrators who control the policies that determine whether hospitals facilitate breastfeeding or not. CWA attracted news coverage for the reports to mount pressure on the policy makers in the hospitals.

As with the national news articles we examined, the CWA reports detailed the link between breastfeeding and Health benefits; however, they took a more comprehensive approach, explaining breastfeeding's benefits — not just for children, but for women, families and entire communities. Additionally, CWA did not fall into the trap of discussing breastfeeding as merely an individual woman's decision. Instead, CWA contextualized the Good Mother frame, showing that breastfeeding rates are the outcome of many factors including hospital policies, workplace policies, and other types of social support for breastfeeding. This helps explain why breastfeeding rates vary so widely from region to region: The places in California with the poorest health outcomes tend to be the places with the least support for breastfeeding. CWA ended each report with a list of recommendations to help hospital administrators, policy makers and other community decision makers increase breastfeeding rates.

CWA's reports were picked up widely in California news media. The result: Reporters used the same frames as CWA, emphasizing the role of environmental factors in influencing personal choice and offering a more thorough view of breastfeeding's benefits. These frames dominated CWA's news coverage: Successful Breastfeeding Requires Support, Breastfeeding Benefits Women's Health, and Well Supported Breastfeeding Brings Well-being to All.

Successful Breastfeeding Requires Support

This frame contends that increasing exclusive breastfeeding rates and decreasing health disparities is only possible if women's efforts to breastfeed are supported by structural changes at the policy level. These efforts include eliminating the marketing of free formula, improving staff training and breastfeeding policies at hospitals, reducing language, cultureand income-based barriers to breastfeeding support services, and expanding legislation that supports breastfeeding by working mothers. Susan Buckley, director of Maternal Child and Adolescent Health for the Department of Health and Human Services, expresses this frame in a Eureka Reporter article: "It's a real long commitment, and there are pressures to supplement, to return to work. We need more societal support. We need to make sure the workplace creates a supportive environment."

Breastfeeding Benefits Women's Health

This frame discusses breastfeeding as it relates to various health benefits for the mother, including decreased risks of osteoporosis, breast and ovarian cancers, anemia, and type-2 diabetes. It parallels the way health benefits are described for the baby.

Well Supported Breastfeeding Brings Well-being to All

This frame extends the Breastfeeding Ensures Healthy Babies and Women Have Needs Too frames to the whole community. When mothers and children are healthy, the whole family — and even the whole community — benefits. One speaker expands the Health frame in this direction when she says, "The evidence is so overwhelming that breast-fed babies have a lower incidence of respiratory illness, gastrointestinal problems and childhood obesity. We are beginning to look at this more and more as a community health opportunity."21 Fewer illnesses mean lower expenses, less time away from work and less stress, which is how some advocates frame the issue to garner support from the business sector. "Emily Lindsey, chairwoman of the Merced County Breastfeeding Coalition, said that she is hearing of more businesses following Memorial's lead but there are still employers who despite state law, aren't willing to risk loss in work production. 'A lot of them think it will cost them money because the employee isn't working,' Lindsey said. 'But it actually saves them money because women don't have to take the day off.'"22

Apart from direct health benefits, and even economic benefit, this frame suggests that the nurturing environment that values breastfeeding would have generalized community cohesion benefits as well because it would be evidence of strong support for babies, women, and families. From CWA's viewpoint, communities and workplaces that support and facilitate breastfeeding would lead to well-being for everyone. Hospitals — important institutions in most communities — fit in this frame comfortably.

Summary

Framing matters because there are no blank slates. All people come to the information that they see, read or hear with ideas already in their heads about the way the world works. Those prior notions influence the way people make sense of and extract meaning from the new information they encounter. So when advocates or journalists write about public health issues such as breastfeeding, the messages they send always bump up against and either reinforce or compete with readers' existing ideas about that topic. Some frames such as the Good Mother portray breastfeeding as a function of individual mothers, rather than an outcome of a society that supports women, children and families. That frame is so entrenched in our culture and in our minds that it takes repeated, strategic efforts to overcome it and change people's understanding of breastfeeding so that they see not just the act itself but the context of real women's lives in which it takes place.

Efforts such as the California WIC Association's to reframe breastfeeding in the news are crucial to making that context visible. Once the context is in the foreground, advocates will be better positioned to shape public opinion and create support for the policies that will help eliminate the barriers that make breastfeeding difficult for large numbers of women. Such policies are necessary to improve exclusive breastfeeding rates in hospitals and elsewhere. Increased media advocacy from organizations like CWA can help move us in that direction.

Recommendations for advocates

The California WIC Association has emphasized both the health benefits of breastfeeding and the need for strong social support for women and babies to further its goal of improving policies and practices in hospitals. This effort has been successful — CWA's message is strong and consistently picked up and amplified by news coverage. It is an important step toward reframing public conversations and reshaping cultural attitudes about breastfeeding.

Even so, more needs to be done to amplify this message and others that can help people see the context surrounding the Good Mother and support the policy changes that will ensure environments support breastfeeding. Toward that end, we make the following recommendations for CWA and other advocates interested in supporting breastfeeding.

Do more media advocacy

The California WIC Association successfully framed breastfeeding within a larger social and institutional context. Its commitment to regularly conduct research, write newsworthy reports, and do media advocacy to ensure journalists report on the findings should be enhanced and expanded by other advocates in the field.

Media advocacy is the strategic use of mass media to support community organizing and policy advocacy. To do it well, advocates should remember its key points:

  • You can't have a media strategy without an overall strategy.
    The desired policy change drives the message, not the other way around. Once advocates have identified those policies, then they can determine the media and message strategies to follow. With those in place, advocates are ready to attract the attention of journalists to raise the issue on the agenda, framed in a way that highlights the solution they seek. Messages about the health benefits of breastfeeding will reinforce an individualized Good Mother frame unless the messages also call out the policy context that can support breastfeeding.
  • The primary target is never the general public.
    The object of media advocacy is to put pressure on decision makers to make the right decision for the public's health. Media advocates focus on getting news coverage to put pressure on those decision makers. Secondary audiences are those people who can put direct pressure on the primary target. Educating the general public happens in the context of reaching the primary target, usually a policy maker or governing body.
  • Be proactive and reactive.
    Media advocacy can be planned, as were the California WIC Association's hospital reports. And breastfeeding advocates can prepare themselves and their organizations to be responsive when news breaks. To do that well, advocates and their organizations need to practice good media relations: Get to know key reporters and bloggers, be sure they know you, keep an up-to-date media list, and understand what's newsworthy and how to pitch a story. And, of course, think in terms of the larger frame, so that your social change goals are present in whatever communication you have with journalists.
  • Frame the landscape, not just the portrait.
    Health messages about breastfeeding can educate the general public, but education alone cannot create an environment that supports breastfeeding. If the goal is structural or environmental changes that support breastfeeding, then advocates' messages must illustrate the landscape that surrounds breastfeeding mothers to make visible why those structural changes are needed. And the messages must link the policy changes to that landscape.

    One way advocates can expand their media advocacy is to read the news critically to identify the types of stories that could include links to social changes that would support breastfeeding. Consider how you would fill in the blanks in the following sentences:

    Every time there's a story on _________, it should mention breastfeeding.
    Every time there's a story on breastfeeding, it should mention_________.

    Filling in those blanks, and then acting on the answers, will help advocates find places to apply media advocacy and expand the public conversation on breastfeeding so it encompasses more than individual mothers' decisions.

Put individual policy goals in the context of the overall social change agenda

The California WIC Association has framed its policy change message of promoting Baby-Friendly hospitals to reinforce its overall message about the value of breastfeeding for babies, mothers, and society. CWA's broader goal is to establish an equitable infrastructure that supports the health needs of both women and babies. Highlighting the lack of infrastructure for family support reveals vast inequities in access to breastfeeding facilities: Why do Starbucks' executives get lactation rooms, while baristas have to lock themselves in the bathroom to pump breast milk?23 This question is easier asked than answered. But by cueing the social change goal (greater social infrastructure), policy goals (achieving breastfeeding-friendly workplaces, or Baby-Friendly hospitals) can be aligned with that larger vision. From this perspective, CWA's campaign to ensure hospital policy facilitates breastfeeding is simply one instance of creating a society that supports families in building a healthy future. Hospitals are an important institution to focus on since most babies are born there, yet they are only one institution among many that must support breastfeeding if our society is to create healthy futures for all families.

The context matters, and its importance needs to be made explicit. Repeating the health benefits of breastfeeding without including the context suggests that the major impediment to breastfeeding is that mothers do not know its value. For some that may be true. But the CWA survey data indicate that women know there are health benefits, yet they still do not breastfeed as much as they intend. An education program to inform women about the health benefits to their babies or themselves will not help if the social and structural barriers to breastfeeding are not removed.24

Keep mothers — and society — inside the frame

Even when discussing specific policy goals such as Baby-Friendly hospitals, advocates should be sure that mothers are part of the picture as more than breast milk delivery systems. Focusing on mothers as active participants will help dispel the notion that the health needs of babies are inherently at odds with the mothers' needs. CWA can improve its already strong efforts on this front by advocating that Baby-Friendly hospitals be reconceived as Mother-Friendly and Baby-Friendly hospitals. CWA's "Mother-Baby Friendly Workplace Awards"25 provide a perfect example of reinforcing a frame that includes both mothers and babies. This conceptualization stands as a model communication strategy that supports mothers as well as babies and offers a policy message copacetic with CWA's social change goal.

Similarly, advocates should broaden the picture on breastfeeding. Too often, the story on breastfeeding is narrowly framed around the mother and child. And framing literature tells us that unless we explicitly change the picture, it will be hard for audiences to see why policy matters. Advocates should ask themselves: What happens when we pull the lens back from the mother and child? What comes into focus then? It might be the workplace, the hospital, the community, or other institutions. To expand the frame, advocates should explicitly discuss whichever aspect of the broader environment links logically to their immediate policy goal.

Recommendations for reporters

Journalists play an important role in shaping the ongoing debate about breastfeeding. The stories they write, the information they choose to include or exclude from those stories, and the sources they use to support them all influence both the opinions of policy makers and the general public. When journalists encounter studies about breastfeeding, they can report on the findings alone or expand the story, seeking out the context behind the numbers. Journalists who covered CWA's reports on breastfeeding did not have to look far for that context because the reports included it. But not all studies are so comprehensive, and journalists should be prepared to ask, What's missing? What would make this story more complete?

Investigate why women breastfeed less than they intend

Many studies and the news coverage that follows convey the same primary pieces of information: 1) breastfeeding has tremendous health benefits for babies and 2) not enough mothers breastfeed. These stories risk pointing a scolding finger, and however unintentionally, holding mothers solely responsible for breastfeeding successes or failures. Reporters should look beyond the portrait of the individual mother to the environment she lives in and investigate the social and cultural factors that make it difficult or undesirable to breastfeed. Do some communities or workplaces make breastfeeding easier than others? To what effect? What would it take for workplaces and other community spaces to support breastfeeding, and what changes should we expect if that happened? Could those changes happen in your community?

Explore the full range of breastfeeding's benefits

News stories often enumerate breastfeeding's many health benefits to babies — both now and later in life. While advocates like the California WIC Association have focused on health benefits, the organization believes that widespread support for breastfeeding benefits society in general. Journalists should ask: Why do they think that is the case? What other benefits are there? Journalists' investigations could illuminate how breastfeeding can benefit mothers, fathers, siblings and entire communities.

Put women in context

There's no shortage of breastfeeding stories that talk about mothers. But it's harder to find articles that feature their voices and give them a chance to do some of the talking. No facts or statistics can replicate the lived experience of a mother who breastfeeds. Besides providing added perspectives as to why women do or do not breastfeed, quoting women brings mothers into the conversation and lessens the risk of alienating the very readers who are most affected by stories on breastfeeding. When adding mothers' voices to the story, reporters should be sure to couch them within a bigger picture context so that a mother's successes or difficulties with breastfeeding can be understood in relation to society's successes or failures in supporting breastfeeding, rather than outcomes solely attributable to that individual mom.

Conclusion

When advocates make a concerted effort to reframe news on breastfeeding, they can succeed. The problem remains, however, that efforts like those of the California WIC Association represent only a small amount of news coverage against a large backdrop of cultural frames that highlight individualism and reify an idealized Good Mother.

This lack of context was one of Rosin's primary complaints in her Atlantic article: "The debate about breastfeeding takes place without any reference to its actual context in women's lives," she writes. "Breastfeeding exclusively is not like taking a prenatal vitamin. It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way."26

Breastfeeding advocates want the same thing: a world that supports women in every decision and makes it easier for mothers to also participate in the workplace and lead fulfilling lives in whatever manner they choose.

The question for advocates is: What frames are they cueing, illustrating and repeating? Do those frames make it easier for people to see the broader context for breastfeeding? When they do, then advocates will be making the case they want: that a society that supports breastfeeding — in all its institutions, from hospitals to workplaces — is a society that supports families and healthy communities. The policy change process can be tedious and incremental, but we may make those changes faster if we can connect the incremental to our long-term vision. We'll know that vision is realized when Maggie Gyllenhaal or Angelina Jolie breastfeeds in public and no one bothers to get out the camera.

Issue 18 was written by Lori Dorfman, DrPH, and Heather Gehlert, MJ, based on research by Pamela Morgan, PhD. Eliana Bukofzer, MPH, provided research assistance. These findings were first presented at "The Breastfeeding Environment: Re-think, Re- frame, REFORM!" during the 5th Biennial Childhood Obesity Conference, Los Angeles, June 9–12, 2009.

Issue 18 was commissioned by the California WIC Association with support from The California Endowment. We thank Karen Farley and Laurie True for their thoughtful contri- butions and reflections on our findings and for supporting this study.

Issue is edited by Lori Dorfman.

© 2010 Berkeley Media Studies Group, a project of the Public Health Institute

References

1 Gould, Emily. Maggie Gyllenhaal Is a Feminist Superhero. Gawker.com, June 6, 2007. http://gawker.com/266511/maggie-gyllenhaal-is-a-feminist-superhero.

2 Angelina Jolie Breastfeeding — W Magazine Preview. Just Jared, October 9, 2008. http://justjared.buzznet.com/2008/10/09/angelina-jolie-breastfeeding-w-magazine.

3 Rosin, Hanna. The Case Against Breastfeeding. Atlantic, April 2009.

4 Centers for Disease Control, Breastfeeding Report Card — United States, 2009. http://www.cdc.gov/breastfeeding/pdf/2008BreastfeedingReportCard.pdf.

5 Depends on Where You Are Born: California Hospitals Must Close the Gap in Exclusive Breastfeeding Rates. California WIC Association and UC Davis Human Lactation Center, September 2008.

6 Depends on Where You Are Born: California Hospitals Must Close the Gap in Exclusive Breastfeeding Rates. California WIC Association and UC Davis Human Lactation Center, September 2008.

7 A Fair Start for Better Health: California Hospitals Must Close the Gap in Exclusive Breastfeeding Rates. California WIC Association and UC Davis Human Lactation Center, November 2007.

8 86 US Baby-Friendly Hospitals and Birth Centers as of December 2009. BabyFriendly USA. http://www.babyfriendlyusa.org/eng/03.html.

9 See Iyengar, Shanto. Is Anyone Responsible? Chicago IL: University of Chicago Press, 1991.

10 Theriault, Denis C. At El Camino, 95 percent of moms choose breast-feeding. San Jose Mercury News, September 4, 2007.

11 Sorba, Michael. Formula, or milk? Breast-feeding in hospital ranks low here. San Bernardino County Sun, November 24, 2007.

12 Joan Younger Meek, from the US Breastfeeding Committee's response to Hanna Rosin, March 26, 2009.

13 Similac. http://similac.com/baby-formula/store-brands.

14 Sutter Davis ranks sixth in state in breastfeeding rate. The Davis Enterprise, October 31, 2007.

15 Dean, Jennifer. Report looks at breast-feeding rates. The Press Enterprise, September 2, 2008.

16 Sorba, Michael. Formula, or milk? Breast-feeding in hospital ranks low here. San Bernardino County Sun, November 24, 2007.

17 Dean, Jennifer. Report looks at breast-feeding rates. The Press Enterprise, September 2, 2008.

18 Theriault, Denis C. At El Camino, 95 percent of moms choose breast-feeding. San Jose Mercury News, September 4, 2007.

19 Quote by Arcelia Jaramillo from Palaces, Yeny. August is the month to understand the importance of maternal milk. La Opinion, July 28, 2007.

20 Depends on Where You Are Born: California Hospitals Must Close the Gap in Exclusive Breastfeeding Rates. California WIC Association and UC Davis Human Lactation Center, September 2008.

21 Griffith, Dorsey. Good start for breast-feeding can depend on the hospital. The Sacramento Bee, November 24, 2007.

22 Perez, Minerva. Hospital declared 'friendly' to working mothers with infants. Los Banos Enterprise, December 4, 2007.

23 Kantor, Jodi. On the Job, Nursing Mothers Find a 2-Class System. New York Times, September 1, 2006. http://www.nytimes.com/2006/09/01/health/01nurse.html. Accessed 11/12/09.

24 See Bernice L. Hausman: Motherhood and Inequality: A Commentary on Hanna Rosin's "The Case Against Breastfeeding." Journal of Human Lactation. 2009; 25:266268.

25 Breastfeeding Initiatives: Mother Baby Friendly Workplaces. California WIC Association. http://calwic.org/focus-areas/breastfeeding. Accessed 11/01/2011.

26 Rosin, Hanna. The Case Against Breast-Feeding. The Atlantic, April 2009.

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