The Role of Propaganda in Maternal Health Messages
April 2017
The ability to make an informed decision is paramount to the receipt of ethical healthcare. The use of propaganda in healthcare messaging inherently denies people this right. Propaganda involves a message that promotes beliefs that are misleading about what is true or false, with an emphasis on claims or conclusions made, and with a deemphasis on factual evidence (Gambrill, 2012).
The use of propaganda to further one’s cause is a technique that is perhaps as old as society itself. It relies on identity systems- to either use an existing (societal or self) identity or to influence changes within one- to generate cognitive dissonance, therefore making it easier to persuade people (Schapiro & Ambrose, 2015). Propaganda can have a profound influence on societal morals, which are continually evolving as cultures mature and grow. As evidenced by slavery, women’s oppression and Jim Crow being legal and socially acceptable in periods of our history, even the morally reprehensible can be delivered to the masses as being justified and even good for a society. Every generation is raised with an integration of the debates of previous generations into the fabric of their collective moral tapestry, with occasional reinterpretations of issues which still surface from time to time (Edge & Groves, 2006).
Propaganda is a conditioning procedure not unlike what was found in the famous study that Ivan Pavlov used on his dogs; training them to salivate when they hear a bell ring. Similar psychological techniques were employed by John B. Watson in radio advertisements, conditioning Americans to buy certain products. These same techniques are used today by a wide variety of companies, who apply these techniques without any awareness of the people being conditioned (Parish & Parish, 2016).
Sometimes healthcare propaganda achieves a positive result. In the 1940s, the former Soviet Union experienced a nationwide shortage of pain medication. In response, Soviet scientists invented a “psychoprophylactic method of painless childbirth” that later evolved into the Lamaze method that is known throughout the Western world today. They believed that the mind needed to be conditioned in order to alter the perception of pain and presented the method as an important pain management method without divulging that there were only psychological methods at work to account for its efficacy (Hrešanová, 2016). This was based on the now famous Pavlov experiment exemplifying operant conditioning and as we can tell from its popularity through the decades, it is quite effective.
One way we can explain the efficacy of propaganda is to consider the Heuristic-Systematic Model (HSM) of decision-making. This model includes two primary methods of processing messages within the individual. The Systematic processing of information involves careful examination of differing arguments, comparing and relating them to one another before a decision is made. It is within this manner of thought that one can make a truly informed health care decision. The Heuristic process is one in which the careful examination is short-cut by quick judgments (such as the use of a general rule of thumb or social consensus). Both processes fall on their own spectrum and can explain a great many decisions made by the general population. Choices made by Systematic processes tend to be more stable and long-lasting than choices made with Heuristic processes (Berry, 2006).
As we examine propaganda through an HSM lens, we can clearly see why it is so effective. The old adage “Breast is Best” is clearly a form of propaganda, as it is succinct and presents a conclusion without offering any evidence to the receiver of the message. In fact, science shows that the catchier the slogan, the better- as it will be more easily recalled and repetition is a key factor of successful propaganda (Gambrill, 2012). Even if the creator of the propaganda has noble intentions, there are always likely to be an outward ripple effect which may at some point distort the public’s perception of the message.
This effect called the “Validity Effect,” can have adverse consequences. It has been shown that developing a familiarity with a concept, regardless of its factual validity, gives us the feeling that we know more about it than we actually do when the information is discussed at a later date (Gambrill, 2012). That is, the more someone is exposed to the adage “Breast is Best” they will use heuristic systems of thought to make their healthcare decisions and therefore skip a systematic and evidence-based decision-making method that is based on critical thought (Barry, 2006). In other words, they may be able to parrot that “breast is best” and choose to either nurse or formula feed their babies, but still not be able to say why breastfeeding is a healthier choice over formula feeding or what risks are carried by a choice to skip breastfeeding altogether.
These concepts converge to make what can only be described as an “illusion of choice” for feeding practices. Mothers are bombarded with tired adages so vague as “breast is best,” which have been expertly corroborated by the formula companies. They go so far as to expound upon it on every can of formula and bit of advertising that “Breast is best, BUT…” It is easy to see how heuristic processes, in combination with the Validity effect, can play a role in such low rates of exclusive breastfeeding.
In the US, this illusion of choice results in a “damned if you do/damned if you don’t” culture. If a mother does choose to nurse her baby, it is culturally unacceptable to nurse in public or discuss it with others for fear that she would be labeled as a “lactivist” or accused of passing judgment upon others for making different choices. If she chooses not to nurse her baby then some brazen individuals may assume (or say out loud if they are emboldened enough) that the must not want what’s best for her baby, that she is selfish or ignorant. Even if nobody did say those things directly to her, she can easily read between the lines in articles she reads or in advertising she sees. She may also be her own worst critic- especially if she wanted to breastfeed but felt she could not succeed. We can see how there is no winning choice to be made, and this cultural phenomenon is exploited by the “Us vs Them” rhetoric found in mostly pro-formula feeding propaganda. This exploits these feelings of defensiveness for any decision made and encourages cognitive dissonance in those who may not have ever had a single negative word spoken towards them -and who is in fact in an extreme majority, as just 18.8% of mothers are nursing without supplementation at 6 months (CDC, 2014).
This rhetoric even gained national attention with an untold amount of free advertising for Similac after they aired their “Mother ‘Hood” ad, where self-righteous “Breast is Best” moms faced off against formula feeding moms, working moms, baby wearing moms, and a variety of other parental stereotypes (CNN, 2015). This ad is a stroke of propagandizing/advertising brilliance as it absolves formula feeding mothers (depicted as the only “normal” group) from all of their perceived shame while simultaneously shaming everyone else. This type of propaganda seeks to influence changes within one’s social identity- to generate cognitive dissonance, therefore making it easier to persuade people (Schapiro & Ambrose, 2015)- in this case, that those who are pro-breastfeeding (or, pretty much those who are not formula feeding) are inherently judgmental and looking down upon those who have differing parenting philosophies.
It can be particularly challenging for those who are relying simply on heuristic systems to gather high-quality information from the media. There seems to be no shortage of those who speak with authority but do not have the facts, experience and/or education to back it up. By taking heuristic shortcuts, one may accept assertions made in propaganda messages as truth simply because they sound plausible, or because they like the individual or agency making the assertion. It may even be that simply because the reader is in a good mood that they are more likely to utilize heuristic methods of decision making (Berry, 2006).
So, if the extreme majority of women do breastfeed their children at some point- nearly 80% - but just 18% of them nursing without supplementation 6 months later (CDC, 2014), what happens through those immediate postpartum months?
There is no single answer to this question. Many factors influence a mother’s success with breastfeeding. An incredibly high number of breastfed babies (roughly one-third) are supplemented with formula before their second day of life (CDC, 2014). In-hospital formula supplementation has been shown to negatively impact breastfeeding duration (Semenic, Loiselle, & Gottlieb, 2008). In fact, in-hospital supplementation among babies whose mothers intended to exclusively breastfeed was associated with almost double the risk of not nursing exclusively between 1 and 2 months of age, and nearly triple the risk of complete cessation of breastfeeding by 2 months of age (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014).
Why are hospitals supplementing babies with so much formula, you may ask? There are a variety of answers to this question. Most notably, supplementation happens because the percentage of weight loss in a newborn exceeds the recommendations by the American Academy of Pediatrics- with normal weight loss being 7% (but not to exceed 10%) of birth weight in the hospital (AAP, n.d.). The most recent data available from the Centers for Disease Control (2015) indicate that the cesarean section in the United States hovers around 32% of births. This is in spite of the World Health Organization, who in that same year recommended that cesareans would be appropriately utilized in just 10-15% of births. The commonly accepted notion gleaned from these facts is that the US has too many cesareans, and hospitals are under pressure to lower the rates of cesarean section for their patients.
Scheduled cesarean births, when there is no prior labor, may be a risk factor for increased weight loss in the newborn (Mezzacappa, & Ferreira, 2016; Weight Loss in Exclusively Breastfed Infants Delivered by Cesarean Birth, 2012). Additionally, it has been found that these breastfeeding infants born by cesarean who lose a greater percentage of weight than the AAP recommends might actually be experiencing what is termed “physiologic diuresis” after birth- they were simply born with edema (presumably caused by maternal IV fluid intake). This weight loss would be completely unrelated to their breastfeeding behavior (Mulder, Johnson, & Baker, 2010).
We have a plethora of evidence that weight loss deemed to be excessive can feed into maternal anxiety and perceptions of insufficient milk supply. A recent study demonstrated that when a baby has excessive weight loss after birth, their mother tends to have concerns about her milk supply adequacy and were significantly less likely to still breastfeed by the time their babies reach 6 months of age (Flaherman, Beiler, Cabana, & Paul, 2016).
Sometimes, however, the recommendations that adversely impact breastfeeding come down to simple, honest ignorance of the physiologic process. Studies have shown that just 38% of OB/GYN Residents had received any breastfeeding training whatsoever and that personal experience with breastfeeding was the driving force behind whether the residents believed they were effective in helping mothers with breastfeeding issues (Freed, Clark, Cefalo & Sorenson, 1995a). Indeed, even family physicians and pediatricians have staggering rates of education (in some cases, nothing, and in other cases, a single lecture during classroom work) and knowledge about breastfeeding (Freed, Clark, Cefalo & Sorenson, 1995b). While this data is just over 20 years old, many hospital policies are made by physicians who earned their credentials during the time period in which the (quite large) studies were conducted, and these are the practitioners who are training the newer generation of caregivers. Given this lack of education on the part of medical caregivers, in combination with the fact that they are also, indeed, human, it seems that many people overlook the susceptibility on the part of physicians to healthcare propaganda. Indeed, the Baby Friendly Initiative indirectly acknowledges that hospitals have much room for improvement in this area, yet many hospitals choose not to seek this voluntary accreditation. Why? It is entirely possible that many of these physicians and decision-makers fall victim to believing infant formula propaganda and repeat the messages they gleaned from advertising and relay it to patients, who- in turn- utilize heuristic thought processes and blindly accept the propaganda as fact since they are receiving it from a trusted source they assume is well-educated.
And where is the mother’s responsibility in this? Often, those who wanted to breastfeed, but were set up for failure (whether because of an unnecessary cesarean, unnecessary supplementation or inadequately trained lactation support), might blame themselves for not speaking up- especially if the advice given by practitioners or policies followed in the hospital are incongruent with her maternal instincts. Of course she is stuck between a rock and a hard place.
The fact is, we are conditioned from the time that we are very young- especially as women- that we must accept the word of anyone in a position of authority (such as a physician) as the final truth. Questioning claims that come from alleged authorities are often met with hostility, by the authority figures themselves and also from miscellaneous support people in their lives. Those who question authority are considered deviants and often experience social repercussions for questioning things that others accept to be fact (Gabrill, 2012).
Regardless of the immediate postpartum in-hospital experience, the thing we can be assured of is that the parents will be bombarded with advertising and public service messages regarding how to feed their children. This messaging can come from her obstetrician or midwife’s office, pediatric or family physician practice, on television, in print, or on social media. Perhaps now more than any other period in history, women are bombarded with conflicting propaganda at every turn.
A tactic which seems obvious to the critical thinker but nonetheless must be effective (or else it wouldn’t be such a pervasive tactic) is for a company to make a website they claim to be with the intention of “educating” the public on a subject matter which may be in direct conflict with their business interests (Gambrill, 2012). Formula companies do this all the time.
A particularly unethical piece of propaganda displayed on Enfamil’s website is a claim that supplementing with formula can prolong overall breastfeeding duration. They use a variety of techniques designed to appeal to the heuristic processes in moms riddled with anxieties or under the weight of social pressures and look upon feeding formula as a beneficial choice, even for nursing parents (Enfamil, 2015) - despite a myriad of evidence that formula supplementation harms the breastfeeding relationship (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Semenic, S., Loiselle, C., & Gottlieb, 2008; Flaherman, Beiler, J. S., Cabana, & Paul, 2016).
Even the name of the company Similac is propaganda, as it implies that their product is “similar to lactation,” or some type of equivalent to breastmilk. Beyond this, their “Sisterhood of Motherhood” campaign blatantly propagandizes women to thinking there’s an external force- other parents- that judge them at every turn (Similac, 2017). We can see how the very “mommy war” they sought to shame parents for engaging in via their “Mother ‘Hood” campaign is largely created and perpetuated by the formula industry themselves. It is interesting to consider this from the perspective that formula feeding parents make up more than 80% of parents by the time their babies are a year old, yet the industry will portray them as a helpless minority, bullied by the throngs (who represent an extreme minority- less than 1 in 5 moms) of breastfeeding parents and medical professionals.
Whether it is ever ethical to propagandize the public is certainly ripe for debate. Democratic republics like ours are populated by democratically elected officials who are supposed to represent the views and moral character of the masses who voted them in. To an extent, one could argue that since it’s their job to represent the will of the people, that the people should be able to trust that they can use heuristic processes to decide whether they want to go along with what their governmental representatives do.
On the other hand, as evidenced by the current political climate in the US, there is a valid argument that the will of the people may be overly decided by heuristic processes; ultimately that is to the people’s detriment. Even in the case of something that science unequivocally supports, such as “breast is best,” the difficulty accessing the full scope of information in a concise manner clearly needs to be remedied.
Perhaps, if all advertising (whether for businesses or government agencies) required source citations in their claims, we’d at least have the opportunity to examine these claims in a systematic manner. The use of propaganda in health messaging inherently deprives people of their fundamental right to have access to the full breadth of information necessary in order to make a truly informed decision.
References:
American Academy of Pediatrics (n.d.). Retrieved from https://www2.aap.org/breastfeeding/curriculum/documents/pdf/hospital%20breastfeeding%20policy_final.pdf
Berry, D. (2006) Health Psychology: Health Communication: Theory And Practice. Buckingham, US: Open University Press
Center for Disease Control (2014) Breastfeeding Report Card Retrieved from http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
Center for Disease Control (2015). FastStats. Retrieved April 14, 2017, from https://www.cdc.gov/nchs/fastats/delivery.htm
Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, E. A., & Nommsen-Rivers, L. A. (2014). Original Article: In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed. The Journal Of Pediatrics, 1641339-1345.e5. doi:10.1016/j.jpeds.2013.12.035
CNN, K. W. (2015). Similac commercial is a hit with the parenting crowd. Retrieved April 6, 2017, from http://www.cnn.com/2015/01/28/living/feat-similac-ad-parenting/index.html
Edge, R.S. & Groves, J.R. (2006) Ethics of Healthcare: A Guide for Clinical Practice (3rd ed.). Clifton Park, NY: Cengage Learning.
Enfamil (2015). How Supplementing Helped These Moms Breastfeed Longer. Retrieved April 12, 2017, from https://www.enfamil.com/articles-and-videos/feeding-resources-center/supplementing/how-supplementing-helped-these-moms-breastfeed-longer
Freed, G. L., Clark, S. J., Cefalo, R. C., & Sorenson, J. R. (1995a). Breast-feeding education of obstetrics-gynecology residents and practitioners. American Journal of Obstetrics and Gynecology, 173(5), 1607–1613. https://doi.org/10.1016/0002-9378(95)90656-8
Freed, G. L., Clark, S. J., Sorenson, J., Lohr, J. A., Cefalo, R., & Curtis, P. (1995b). National Assessment of Physicians’ Breast-feeding Knowledge, Attitudes, Training, and Experience. JAMA, 273(6), 472–476. https://doi.org/10.1001/jama.1995.03520300046035
Flaherman, V. J., Beiler, J. S., Cabana, M. D., & Paul, I. M. (2016). Relationship of newborn weight loss to milk supply concern and anxiety: the impact on breastfeeding duration. Maternal And Child Nutrition, (3), 463. doi:10.1111/mcn.12171
Gambrill, E. D. (2012). Propaganda in the Helping Professions. New York, NY: Oxford University Press.
Hrešanová, E. (2016). The Psychoprophylactic Method of Painless Childbirth in Socialist Czechoslovakia: from State Propaganda to Activism of Enthusiasts. Medical History, 60(4), 534-556. doi:10.1017/mdh.2016.59
Mezzacappa, M. A., & Ferreira, B. G. (2016). Original article: Excessive weight loss in exclusively breastfed full-term newborns in a Baby-Friendly Hospital. Revista Paulista De Pediatria (English Edition), 34281-286. doi:10.1016/j.rppede.2016.03.003
Mulder, P. J., Johnson, T. S., & Baker, L. C. (2010). Excessive weight loss in breastfed infants during the postpartum hospitalization. Journal Of Obstetric, Gynecologic, & Neonatal Nursing: Clinical Scholarship For The Care Of Women, Childbearing Families, & Newborns, 39(1), 15-26. doi:10.1111/j.1552-6909.2009.01085.x
Parish, T. S., & Parish, J. G. (2016). A comparison of external and internal control psychology. International Journal Of Choice Theory And Reality Therapy, 35(2), 10-13.
Schapiro, B., & Ambrose, S. H. (2015). On the origins of propaganda: Bio-cultural and evolutionary perspectives on social cohesion. In M. Grabowski, M. Grabowski (Eds.) , Neuroscience and media: New understandings and representations (pp. 108-132). New York, NY, US: Routledge/Taylor & Francis Group.
Semenic, S., Loiselle, C., & Gottlieb, L. (2008). Predictors of the duration of exclusive breastfeeding among first-time mothers. Research In Nursing & Health, 31(5), 428-441. doi:10.1002/nur.20275
Similac (2017). Sisterhood of MotherhoodT - Embracing Moms | Similac. Retrieved April 10, 2017, from https://similac.com/why-similac/sisterhood-of-motherhood
The ability to make an informed decision is paramount to the receipt of ethical healthcare. The use of propaganda in healthcare messaging inherently denies people this right. Propaganda involves a message that promotes beliefs that are misleading about what is true or false, with an emphasis on claims or conclusions made, and with a deemphasis on factual evidence (Gambrill, 2012).
The use of propaganda to further one’s cause is a technique that is perhaps as old as society itself. It relies on identity systems- to either use an existing (societal or self) identity or to influence changes within one- to generate cognitive dissonance, therefore making it easier to persuade people (Schapiro & Ambrose, 2015). Propaganda can have a profound influence on societal morals, which are continually evolving as cultures mature and grow. As evidenced by slavery, women’s oppression and Jim Crow being legal and socially acceptable in periods of our history, even the morally reprehensible can be delivered to the masses as being justified and even good for a society. Every generation is raised with an integration of the debates of previous generations into the fabric of their collective moral tapestry, with occasional reinterpretations of issues which still surface from time to time (Edge & Groves, 2006).
Propaganda is a conditioning procedure not unlike what was found in the famous study that Ivan Pavlov used on his dogs; training them to salivate when they hear a bell ring. Similar psychological techniques were employed by John B. Watson in radio advertisements, conditioning Americans to buy certain products. These same techniques are used today by a wide variety of companies, who apply these techniques without any awareness of the people being conditioned (Parish & Parish, 2016).
Sometimes healthcare propaganda achieves a positive result. In the 1940s, the former Soviet Union experienced a nationwide shortage of pain medication. In response, Soviet scientists invented a “psychoprophylactic method of painless childbirth” that later evolved into the Lamaze method that is known throughout the Western world today. They believed that the mind needed to be conditioned in order to alter the perception of pain and presented the method as an important pain management method without divulging that there were only psychological methods at work to account for its efficacy (Hrešanová, 2016). This was based on the now famous Pavlov experiment exemplifying operant conditioning and as we can tell from its popularity through the decades, it is quite effective.
One way we can explain the efficacy of propaganda is to consider the Heuristic-Systematic Model (HSM) of decision-making. This model includes two primary methods of processing messages within the individual. The Systematic processing of information involves careful examination of differing arguments, comparing and relating them to one another before a decision is made. It is within this manner of thought that one can make a truly informed health care decision. The Heuristic process is one in which the careful examination is short-cut by quick judgments (such as the use of a general rule of thumb or social consensus). Both processes fall on their own spectrum and can explain a great many decisions made by the general population. Choices made by Systematic processes tend to be more stable and long-lasting than choices made with Heuristic processes (Berry, 2006).
As we examine propaganda through an HSM lens, we can clearly see why it is so effective. The old adage “Breast is Best” is clearly a form of propaganda, as it is succinct and presents a conclusion without offering any evidence to the receiver of the message. In fact, science shows that the catchier the slogan, the better- as it will be more easily recalled and repetition is a key factor of successful propaganda (Gambrill, 2012). Even if the creator of the propaganda has noble intentions, there are always likely to be an outward ripple effect which may at some point distort the public’s perception of the message.
This effect called the “Validity Effect,” can have adverse consequences. It has been shown that developing a familiarity with a concept, regardless of its factual validity, gives us the feeling that we know more about it than we actually do when the information is discussed at a later date (Gambrill, 2012). That is, the more someone is exposed to the adage “Breast is Best” they will use heuristic systems of thought to make their healthcare decisions and therefore skip a systematic and evidence-based decision-making method that is based on critical thought (Barry, 2006). In other words, they may be able to parrot that “breast is best” and choose to either nurse or formula feed their babies, but still not be able to say why breastfeeding is a healthier choice over formula feeding or what risks are carried by a choice to skip breastfeeding altogether.
These concepts converge to make what can only be described as an “illusion of choice” for feeding practices. Mothers are bombarded with tired adages so vague as “breast is best,” which have been expertly corroborated by the formula companies. They go so far as to expound upon it on every can of formula and bit of advertising that “Breast is best, BUT…” It is easy to see how heuristic processes, in combination with the Validity effect, can play a role in such low rates of exclusive breastfeeding.
In the US, this illusion of choice results in a “damned if you do/damned if you don’t” culture. If a mother does choose to nurse her baby, it is culturally unacceptable to nurse in public or discuss it with others for fear that she would be labeled as a “lactivist” or accused of passing judgment upon others for making different choices. If she chooses not to nurse her baby then some brazen individuals may assume (or say out loud if they are emboldened enough) that the must not want what’s best for her baby, that she is selfish or ignorant. Even if nobody did say those things directly to her, she can easily read between the lines in articles she reads or in advertising she sees. She may also be her own worst critic- especially if she wanted to breastfeed but felt she could not succeed. We can see how there is no winning choice to be made, and this cultural phenomenon is exploited by the “Us vs Them” rhetoric found in mostly pro-formula feeding propaganda. This exploits these feelings of defensiveness for any decision made and encourages cognitive dissonance in those who may not have ever had a single negative word spoken towards them -and who is in fact in an extreme majority, as just 18.8% of mothers are nursing without supplementation at 6 months (CDC, 2014).
This rhetoric even gained national attention with an untold amount of free advertising for Similac after they aired their “Mother ‘Hood” ad, where self-righteous “Breast is Best” moms faced off against formula feeding moms, working moms, baby wearing moms, and a variety of other parental stereotypes (CNN, 2015). This ad is a stroke of propagandizing/advertising brilliance as it absolves formula feeding mothers (depicted as the only “normal” group) from all of their perceived shame while simultaneously shaming everyone else. This type of propaganda seeks to influence changes within one’s social identity- to generate cognitive dissonance, therefore making it easier to persuade people (Schapiro & Ambrose, 2015)- in this case, that those who are pro-breastfeeding (or, pretty much those who are not formula feeding) are inherently judgmental and looking down upon those who have differing parenting philosophies.
It can be particularly challenging for those who are relying simply on heuristic systems to gather high-quality information from the media. There seems to be no shortage of those who speak with authority but do not have the facts, experience and/or education to back it up. By taking heuristic shortcuts, one may accept assertions made in propaganda messages as truth simply because they sound plausible, or because they like the individual or agency making the assertion. It may even be that simply because the reader is in a good mood that they are more likely to utilize heuristic methods of decision making (Berry, 2006).
So, if the extreme majority of women do breastfeed their children at some point- nearly 80% - but just 18% of them nursing without supplementation 6 months later (CDC, 2014), what happens through those immediate postpartum months?
There is no single answer to this question. Many factors influence a mother’s success with breastfeeding. An incredibly high number of breastfed babies (roughly one-third) are supplemented with formula before their second day of life (CDC, 2014). In-hospital formula supplementation has been shown to negatively impact breastfeeding duration (Semenic, Loiselle, & Gottlieb, 2008). In fact, in-hospital supplementation among babies whose mothers intended to exclusively breastfeed was associated with almost double the risk of not nursing exclusively between 1 and 2 months of age, and nearly triple the risk of complete cessation of breastfeeding by 2 months of age (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014).
Why are hospitals supplementing babies with so much formula, you may ask? There are a variety of answers to this question. Most notably, supplementation happens because the percentage of weight loss in a newborn exceeds the recommendations by the American Academy of Pediatrics- with normal weight loss being 7% (but not to exceed 10%) of birth weight in the hospital (AAP, n.d.). The most recent data available from the Centers for Disease Control (2015) indicate that the cesarean section in the United States hovers around 32% of births. This is in spite of the World Health Organization, who in that same year recommended that cesareans would be appropriately utilized in just 10-15% of births. The commonly accepted notion gleaned from these facts is that the US has too many cesareans, and hospitals are under pressure to lower the rates of cesarean section for their patients.
Scheduled cesarean births, when there is no prior labor, may be a risk factor for increased weight loss in the newborn (Mezzacappa, & Ferreira, 2016; Weight Loss in Exclusively Breastfed Infants Delivered by Cesarean Birth, 2012). Additionally, it has been found that these breastfeeding infants born by cesarean who lose a greater percentage of weight than the AAP recommends might actually be experiencing what is termed “physiologic diuresis” after birth- they were simply born with edema (presumably caused by maternal IV fluid intake). This weight loss would be completely unrelated to their breastfeeding behavior (Mulder, Johnson, & Baker, 2010).
We have a plethora of evidence that weight loss deemed to be excessive can feed into maternal anxiety and perceptions of insufficient milk supply. A recent study demonstrated that when a baby has excessive weight loss after birth, their mother tends to have concerns about her milk supply adequacy and were significantly less likely to still breastfeed by the time their babies reach 6 months of age (Flaherman, Beiler, Cabana, & Paul, 2016).
Sometimes, however, the recommendations that adversely impact breastfeeding come down to simple, honest ignorance of the physiologic process. Studies have shown that just 38% of OB/GYN Residents had received any breastfeeding training whatsoever and that personal experience with breastfeeding was the driving force behind whether the residents believed they were effective in helping mothers with breastfeeding issues (Freed, Clark, Cefalo & Sorenson, 1995a). Indeed, even family physicians and pediatricians have staggering rates of education (in some cases, nothing, and in other cases, a single lecture during classroom work) and knowledge about breastfeeding (Freed, Clark, Cefalo & Sorenson, 1995b). While this data is just over 20 years old, many hospital policies are made by physicians who earned their credentials during the time period in which the (quite large) studies were conducted, and these are the practitioners who are training the newer generation of caregivers. Given this lack of education on the part of medical caregivers, in combination with the fact that they are also, indeed, human, it seems that many people overlook the susceptibility on the part of physicians to healthcare propaganda. Indeed, the Baby Friendly Initiative indirectly acknowledges that hospitals have much room for improvement in this area, yet many hospitals choose not to seek this voluntary accreditation. Why? It is entirely possible that many of these physicians and decision-makers fall victim to believing infant formula propaganda and repeat the messages they gleaned from advertising and relay it to patients, who- in turn- utilize heuristic thought processes and blindly accept the propaganda as fact since they are receiving it from a trusted source they assume is well-educated.
And where is the mother’s responsibility in this? Often, those who wanted to breastfeed, but were set up for failure (whether because of an unnecessary cesarean, unnecessary supplementation or inadequately trained lactation support), might blame themselves for not speaking up- especially if the advice given by practitioners or policies followed in the hospital are incongruent with her maternal instincts. Of course she is stuck between a rock and a hard place.
The fact is, we are conditioned from the time that we are very young- especially as women- that we must accept the word of anyone in a position of authority (such as a physician) as the final truth. Questioning claims that come from alleged authorities are often met with hostility, by the authority figures themselves and also from miscellaneous support people in their lives. Those who question authority are considered deviants and often experience social repercussions for questioning things that others accept to be fact (Gabrill, 2012).
Regardless of the immediate postpartum in-hospital experience, the thing we can be assured of is that the parents will be bombarded with advertising and public service messages regarding how to feed their children. This messaging can come from her obstetrician or midwife’s office, pediatric or family physician practice, on television, in print, or on social media. Perhaps now more than any other period in history, women are bombarded with conflicting propaganda at every turn.
A tactic which seems obvious to the critical thinker but nonetheless must be effective (or else it wouldn’t be such a pervasive tactic) is for a company to make a website they claim to be with the intention of “educating” the public on a subject matter which may be in direct conflict with their business interests (Gambrill, 2012). Formula companies do this all the time.
A particularly unethical piece of propaganda displayed on Enfamil’s website is a claim that supplementing with formula can prolong overall breastfeeding duration. They use a variety of techniques designed to appeal to the heuristic processes in moms riddled with anxieties or under the weight of social pressures and look upon feeding formula as a beneficial choice, even for nursing parents (Enfamil, 2015) - despite a myriad of evidence that formula supplementation harms the breastfeeding relationship (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Semenic, S., Loiselle, C., & Gottlieb, 2008; Flaherman, Beiler, J. S., Cabana, & Paul, 2016).
Even the name of the company Similac is propaganda, as it implies that their product is “similar to lactation,” or some type of equivalent to breastmilk. Beyond this, their “Sisterhood of Motherhood” campaign blatantly propagandizes women to thinking there’s an external force- other parents- that judge them at every turn (Similac, 2017). We can see how the very “mommy war” they sought to shame parents for engaging in via their “Mother ‘Hood” campaign is largely created and perpetuated by the formula industry themselves. It is interesting to consider this from the perspective that formula feeding parents make up more than 80% of parents by the time their babies are a year old, yet the industry will portray them as a helpless minority, bullied by the throngs (who represent an extreme minority- less than 1 in 5 moms) of breastfeeding parents and medical professionals.
Whether it is ever ethical to propagandize the public is certainly ripe for debate. Democratic republics like ours are populated by democratically elected officials who are supposed to represent the views and moral character of the masses who voted them in. To an extent, one could argue that since it’s their job to represent the will of the people, that the people should be able to trust that they can use heuristic processes to decide whether they want to go along with what their governmental representatives do.
On the other hand, as evidenced by the current political climate in the US, there is a valid argument that the will of the people may be overly decided by heuristic processes; ultimately that is to the people’s detriment. Even in the case of something that science unequivocally supports, such as “breast is best,” the difficulty accessing the full scope of information in a concise manner clearly needs to be remedied.
Perhaps, if all advertising (whether for businesses or government agencies) required source citations in their claims, we’d at least have the opportunity to examine these claims in a systematic manner. The use of propaganda in health messaging inherently deprives people of their fundamental right to have access to the full breadth of information necessary in order to make a truly informed decision.
References:
American Academy of Pediatrics (n.d.). Retrieved from https://www2.aap.org/breastfeeding/curriculum/documents/pdf/hospital%20breastfeeding%20policy_final.pdf
Berry, D. (2006) Health Psychology: Health Communication: Theory And Practice. Buckingham, US: Open University Press
Center for Disease Control (2014) Breastfeeding Report Card Retrieved from http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
Center for Disease Control (2015). FastStats. Retrieved April 14, 2017, from https://www.cdc.gov/nchs/fastats/delivery.htm
Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, E. A., & Nommsen-Rivers, L. A. (2014). Original Article: In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed. The Journal Of Pediatrics, 1641339-1345.e5. doi:10.1016/j.jpeds.2013.12.035
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Enfamil (2015). How Supplementing Helped These Moms Breastfeed Longer. Retrieved April 12, 2017, from https://www.enfamil.com/articles-and-videos/feeding-resources-center/supplementing/how-supplementing-helped-these-moms-breastfeed-longer
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Semenic, S., Loiselle, C., & Gottlieb, L. (2008). Predictors of the duration of exclusive breastfeeding among first-time mothers. Research In Nursing & Health, 31(5), 428-441. doi:10.1002/nur.20275
Similac (2017). Sisterhood of MotherhoodT - Embracing Moms | Similac. Retrieved April 10, 2017, from https://similac.com/why-similac/sisterhood-of-motherhood