Making the case for breastfeeding: The health argument isn't enough

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July 1, 2010

On April 12, 2010, the San Francisco Chronicle printed two letters to the editor on breastfeeding:

Make it easier for new moms

Billions of dollars saved by something that is essentially free breast-feeding should be a no-brainer ("Breast-feeding for 6 months can save lives, money," April 5).

Most moms would do this if it were easy. As a breast-feeding mother and a doctor working with children full time, I can say breast-feeding is not easy. Even with California laws that try to provide protected time and places to pump breast milk, why does it feel as if it would be easier to take a smoking break than a pumping break?

The benefits of breast-feeding are clear. We need to implement existing laws. Each workplace should identify a place and a time for its breastfeeding employees. Bottom line: Our society and the workplace need to embrace the idea that women who work will breast-feed. We will all benefit.
—Holly Martin, MD, San Francisco

The many advantages of breast-feeding

The study that breast-feeding would save lives and money is an excellent discussion that brings light to the significant health and cost benefits of breast-feeding.

Study after study has shown that breasts are best. However, many women who are capable of breast-feeding choose not to do so because they do not quite see the tremendous advantages of breast-feeding that cannot be accomplished through formula feeding.

As a student nurse and future midwife, I am passionate about encouraging and empowering mothers through evidence-based research to make an informed choice to breast-feed if they are capable of doing so. It is essential that we begin to move to a nation that encourages and support [sic] women to breast-feed from day one. It not only saves lives and health care costs, it has huge benefits for the mother. Breastfeeding promotes postpartum weight loss, emotional well-being and bonding with the infant. Breast-feeding has been linked to reduced risks of breast, uterine and ovarian cancer. It also is hugely cost-effective—breast-feeding is free, while formula averages $1,200 a year.
—Deana Harris, student nurse, UCSF

These letters illustrate two different ways advocates talk about breastfeeding. One highlights the barriers that prevent even the most dedicated mothers from breastfeeding. The other touts the health benefits for mothers and babies. In this Framing Brief, we argue that advocates need to emulate and repeat the letter that describes the context for breastfeeding rather than the letter that focuses exclusively on its health benefits.

What's wrong with the health benefits of breastfeeding?

The health benefits are obviously important—that's why advocates want more women to breastfeed—but breastfeeding rates will never increase unless we ensure that institutions like hospitals and workplaces support breastfeeding.

This is because breastfeeding is not simply a function of individual mothers' intent, but rather an outcome of a society that supports women, children and families. Advocates must 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. With the context visible, advocates will be better able to create support for the policies that will make it easier for more women to initiate and continue breastfeeding.

The health argument by itself is not enough because it puts sole attention on the mother and child and none on the circumstances surrounding them. 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 survey data1 indicate that women know there are health benefits, yet they still do not breastfeed as much as they intend.

Health messages about breastfeeding can educate new mothers and the general public, but education alone will not help if the social and structural barriers to breastfeeding are not removed. It would be like entreating mothers to feed their families more fruits and vegetables without considering whether they had access to affordable grocery stores nearby. Or encouraging children to play outside without regard for whether neighborhoods were safe, sidewalks were present, or parks were nearby.

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.

Tell a bigger story about 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.2 Advocates should ask themselves: What do we see when we pull the lens back from the mother and child? 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.

Many studies—and the media stories reporting them—convey the same primary pieces of information:
1) breastfeeding has tremendous health benefits 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. Advocates should look beyond the portrait of the individual mother and describe 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 spaces in your community to support breastfeeding, and what changes should we expect if that happened?

If advocates believe that breastfeeding benefits society at large, they need to describe what that means. They should be able explain how breastfeeding policies benefit people without children.

Advocates should ask themselves: Do we make it easier for people to see the broader context for breastfeeding? When they do, then advocates will be making the case they want: a society that supports breastfeeding—in all its institutions, from hospitals to workplaces—is a society that supports families and health in every community.

Breastfeeding is about health equity

Highlighting the lack of infrastructure for family support reveals vast inequities in access to breastfeeding facilities: For example, why do Starbucks' executives get lactation rooms, while baristas have to lock themselves in the bathroom to pump breast milk?3 Why do many hospitals serving poor mothers have poor support for breastfeeding, while wealthier patients give birth in hospitals that provide plenty of breastfeeding counseling and support? By making the social change goal explicit (an infrastructure for breastfeeding), policy goals (breastfeeding-friendly workplaces and hospitals) can be aligned with that larger vision.

From this perspective, ensuring that hospital and workplace policies facilitate breastfeeding is simply one instance of creating a society that supports families in building a healthy future. Hospitals are a critical institution to focus on since that's where breastfeeding needs to start and is often sabotaged, yet they are but one institution among many that must support breastfeeding if our society is to create healthy futures for all families.

Prime the policy, cue the environment

An effective message answers three questions: What's the problem? What's the solution? Why does it matter? Regardless of the specific policy advocates are pushing, they must connect it to the environmental factors that influence whether or not women breastfeed and ground it in a value that readers can relate to. The components of the message look like this: In the examples below, we've shown how a breastfeeding advocate can use this strategy to influence policy in hospitals, but the same method could apply to workplaces or any other area where added support for breastfeeding is needed. Similarly, the values can be different as long as they reflect the principles you hold. Yet, while each individual component of the message can be changed, they work best together. And order matters. If you put the environmental cue first, then people will better under- stand why the policy matters. Use this equation, and the result--a message that illustrates the need for policies that support breastfeeding--will be the same each time, regardless of the variables.

VALUE: Equity
Women are better able to start breastfeeding and keep at it when the places in which they give birth encourage it.Yet, the gap between breastfeeding services available in low-income communities and more affluent communities is vast. Hospitals in poorer areas are more likely to give mothers free formula samples and less likely to provide help from lactation consultants. It's not fair that women in those communities have less support for something as vital as breastfeeding. Hospital policies should be crafted to remove obstacles to breastfeeding--not create them.

VALUE: Ingenuity
Women are better able to start breastfeeding and keep at it when the places in which they give birth encourage it. Research shows that numerous hospitals throughout California already do so, and they have higher breastfeeding rates as a result. These hospitals have found the way to make breastfeeding work and can serve as models for others. With those policies in place, women and babies in all regions of California can benefit from breastfeeding.

VALUE: Heath
Women are better able to start breastfeeding and keep at it when the places in which they give birth encourage it. When women breastfeed, it benefits their health and the health of their babies. Women who breastfeed have a lower risk of getting breast and ovarian cancers, and their babies are less likely to develop numerous conditions from earaches to diabetes. Hospitals can promote good health by providing mothers with the education and guidance they need to breastfeed.

Interview gone wrong

Once public health advocates know how to frame an issue, they have to learn how to talk about it in public and to reporters. Because policymakers track issues in the news, the way the media portray topics like breastfeeding may influence policy decisions on the issue. Although journalists choose the interview questions, and ultimately, the text that makes it online, on the air, or into print, advocates have a lot of control over how the interview unfolds. Still, that can be easier said than done under the pressure of rapid-fire questions. Staying on message and keeping policy goals in the forefront requires preparation and practice. Without it, even the most seasoned advocate can get off track. Let's see what happens when an advocate trying to create environments that support breastfeeding gets in front of the camera.

REPORTER: A recent report from the Centers for Disease Control shows that breastfeeding rates in the US are very low--about 12%. What accounts for such a low rate?
ANSWER: Women often simply don't have access to the resources they need to breastfeed their children. For example, hospitals should offer education and support for new mothers, and employers need to provide accommo- dations like a private place to express and store milk. Too often, that doesn't happen.

So far so good. Let's keep going.

REPORTER: But what about women's needs? Doesn't the market for formula suggest that many women just prefer not to breastfeed?
ANSWER: Marketers are great at preying on fear and uncertainty. It's true that some women don't wish to breastfeed, but by and large, formula sales aren't a reflection of what women want; they are a reflection of bloated advertising budgets.

REPORTER: For women who do use formula, is it a nutritionally adequate alternative to breastfeeding?
ANSWER: Babies can obviously live on formula, but breast milk is better. Studies have linked breastfeeding to benefits such as improved immunity, decreased risk of heart disease, higher IQs, lower obesity rates and decreased risk of diabetes.These health benefits continue throughout a child's life, long after breastfeeding ends. Formula can't replicate that.

Now you are off track. These answers are valid, but they don't support your goal of increasing structural support for breast- feeding through improved hospital and workplace policies. Instead, the focus has turned to formula marketing and the health benefits of breastfeeding. Let's try it again.

REPORTER: A recent report from the Centers for Disease Control shows that breastfeeding rates in the US are very low--about 12%. What accounts for such a low rate?
ANSWER:
Women often simply don't have access to the resources they need to breastfeed their children. For example, hospitals should offer education and support for new mothers, and employers need to provide accommo- dations like a private place to express and store milk. Too often, that doesn't happen.

REPORTER: But what about women's needs? Doesn't the market for formula suggest that many women just prefer not to breastfeed?
ANSWER: No, it doesn't. In fact, studies show that most women--87% in California--enter the hospital wishing to breastfeed but are undermined along the way. Some medical professionals separate the mother and baby shortly after birth instead of allowing the mother to begin breastfeeding right away; some hospitals provide free formula instead of offering help with breastfeeding; some workplaces expect new mothers back at work shortly after giving birth without providing a place for new mothers to pump and store their breast milk. These barriers can be too great for even the most determined mothers. Formula companies are aware of these obstacles and exploit them to increase their profits.

REPORTER: What are some of the health benefits breastfeeding offers babies?
ANSWER: There are many. Breastfeeding can lower babies' risk of heart disease, strengthen immunity, and possibly even improve IQs. And breastfeeding also decreases the risk of ovarian cancer for mothers. But mothers and babies can enjoy these benefits only if hospitals and workplaces support breastfeeding. Hospital and workplace policies that make it easier for women to breastfeed will lead to healthier mothers and babies and a healthier society overall.

Now you're right on track. The health message is connected to the larger circumstances that determine whether a woman breastfeeds. The reporter can follow up with questions about the policies and what actions are happening locally. Or the re- porter may ask another distracting question. But by staying on track, you will have the discussion you want to have, focused on policies that will help more women be true to their intention to breastfeed.

References

1 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.

2 For an in-depth framing analysis, see Issue 18: Talking About Breastfeeding: Why the Health Argument Isn't Enough.

3 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.

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