Free samples in hospital. Early intensive pacifier use ..

1
Breastfeeding as a Public Health Issue Planning
Promotional Campaigns

• Ted Greiner
• La Leche League Conference, Washington DC, July
  3, 2005

2
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

3
The Components

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

4
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
  strategyits a coping mechanism)
• Photo Baby Milk Action UK.

5
The Components

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

6
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)

7
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

8
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

9
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

10
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

11
Why dont mothers breastfeed exclusively?

• 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

12
Why dont mothers breastfeed exclusively?

• Lack of lactation management/breastfeeding
  counseling
• Lack of confidence (confidence likely to increase
  as knowledge increases)

13
Lack of knowledge

• 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
90936-942, 2001.
14
Time with the baby

• 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

15
Support for doing it right

• 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

16
Relation between support 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)

17
Lack of confidence

• 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)

18
BF promotion methods of 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

19
Professional support

• 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

20
Mass media and social marketing

• Comprehensive, multifaceted
• Variety of audiences (important to segment)
• Evidence of impact
• improves attitudes
• Increases initiation rates and possibly duration

21
Countermarketing and 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

22
Professional education

• 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

23
Public acceptance

• Legislation ensuring the right to breastfeed
• Support to public breastfeeding
• Including breastfeeding in school curricula
• Too little research to know about effectiveness

24
Provision of information

• 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

25
Peer counseling

• 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

26
Norms

• 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 15127-147,
2005.
27
Moderators in the influence of descriptive norms,
I

• 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

28
Moderators in the influence of descriptive norms,
II

• 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)

29
Whos against breastfeeding promotion?

• People whove 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

30
From the babys point of view

• If babies had a voice they would universally
  demand that society take steps to enable them to
  be breastfed
• Theyd 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

31
Recommendations for breastfeeding promotion
campaigns, I

• 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)

32
Recommendations for breastfeeding promotion
campaigns, II

• Texas Dept of health MediaWatch Campaign
  (www.dshs.state.tx.us/wichd/lactate/media.sthm)
• 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

33
Recommendations for breastfeeding promotion
campaigns, III

• 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