SIMPOSIUM DE ENFREMAGEM
Organização
Hospital São Teotónio, EPE, Viseu


Identificação dos autores (apelido, inicial do 1º nome): Paço, A.; Rodrigues, R. G.;
Oliveira, J. M.; Soares, M.; Pires, C.; Duarte, P.; Panaro, M.; Pinheiro, P.; Alves,
H.

Instituição dos autores: Universidade da Beira Interior

Contacto do autor que apresenta comunicação:
Endereço de e-mail: rgrodrigues@ubi.pt
Telefone: +351 275 319 600



TIPO DE COMUNICAÇÃO: Comunicação Oral

TÍTULO DA COMUNICAÇÃO
O papel do Marketing na promoção do aleitamento materno


RESUMO

A finalidade deste trabalho é descrever um programa de Marketing social que visa
promover a adopção e a prevalência do aleitamento materno. Além do impacto na
saúde das mães e de crianças, amamentar tem também um importante impacto
económico, logo é tema socialmente relevante, merecendo investigação adicional.
Esta comunicação descreve os resultados de um questionário administrado a
puérperas, pretendendo avaliar o seu conhecimento, comportamentos e opinião a
respeito da amamentação.
A análise dos resultados indicia que deve ser feito um esforço importante no que se
refere à promoção e à informação sobre o aleitamento materno, devendo-se para isso
utilizar técnicas propostas pelo Marketing.




Introduction
Breastfeeding is a low-cost feeding method that reduces health care utilisation (Kaplan
and Graff, 2008). Moreover, it has been shown that breastfeeding enhances the
mother-baby relationship and thus may decrease the mother’s risk of depression and
anxiety.

Breastfeeding serves as the foundation of health, yet its exclusive practice is declining
(Liddell, 2005). Numerous international initiatives have been created to improve the
initiation, duration, and exclusivity of breastfeeding throughout the world, and several
organizations are working towards these goals.
Definition
There is some discussion about the concept and the meaning of breastfeeding.
Because of that research findings have often been impossible to compare, and
programs have promoted widely divergent patterns. The assumptions of what is
breastfeeding range from "only breastfeeding'" to "at least one breastfeeding," and the
term exclusive has been used to describe situations that varied from "only breast milk
from the breast" to "breast milk is the only source of milk," allowing for the introduction
of other fluids and solids (Labbok and Coffin, 1997).
In order to go beyond this problem, Coffin et al. (1997) suggest the use of a consistent
definitional schema in research, education, and training on breastfeeding. The term
“breastfeeding” alone is not enough to describe the several patterns of breastfeeding
behaviors. In April 1988 a meeting on Definitions of Breastfeeding was held, under the
sponsorship of the Interagency Group for Action on Breastfeeding (IGAB). The schema
that resulted from this summit is described by Labbok and Krasovec (1990) as it can be
seen in Figure 1.

Breastfeeding in the society
With the quickly declining prevalence of breastfeeding in industrialized and developing
countries in the 1950’s and 1960’s, it became evident to health organizations such as
the World Health Organization (WHO) and the United Nations Children’s Fund

(UNICEF) that this trend had extremely serious costs for child health, once that
breastfeeding manifestly reduces the relative risk of morbidity and mortality
(Zetterström, 1999).
Breastfeeding is a low-cost feeding method that reduces health care utilisation (Kaplan
and Graff, 2008). Moreover, it has been shown that breastfeeding enhances the
mother-baby relationship and thus may decrease the mother’s risk of depression and
anxiety.
However, several variables seen to affect negatively breastfeeding behaviour. Alexy
and Carter-Martin (1994) point the lack of education and support, embarrassment,
returning to work or school quickly and distribution of milk substitutes’ free samples.
Breastfeeding is more time consuming than formula feeding, and can initially be
challenging even for mothers who are determined to breastfeed. These and other
factors, such as inconsistent and insufficient support for breastfeeding and easy access
to and high visibility of formula feeding, all contribute to high rates of early
breastfeeding discontinuation (Kaplan and Graff, 2008).
Breastfeeding serves as the foundation of health, yet its exclusive practice is declining
(Liddell, 2005). Numerous international initiatives have been created to improve the
initiation, duration, and exclusivity of breastfeeding throughout the world, and several
organizations are working towards these goals. There are a number of actions that
clinicians can take to build on the foundation of these international initiatives and
national organizations.
Infant formula industry
Since the 19th century, infant formula manufacturers have encouraged mothers to
substitute formula for breast milk. Formula advertisements often claimed that breast
milk alone was not enough to raise a healthy infant (Rosenberg et al., 2008).
Initially when infant formula was introduced, manufacturers advertised their new
product directly to consumers in women’s magazines. Advertisements stated that
babies needed more than just breast milk to achieve optimal health and sustenance,
and they emphasized how strongly formula approximated breast milk’s chemical
composition (Rosenberg et al., 2008)..
The consequence was that mothers and physicians adopted the belief that artificial
feeding was efficient, modern, and scientific. Mothers continued to doubt their capacity
to produce enough milk, especially as women’s magazines popularized mothers’ faulty
ability to breastfeed (Walker, 2007).
Nowadays, formula companies still try to attract new clients with free samples and
information on infant feeding and care. However, several formula companies

abandoned direct-to-consumer advertising and used the medical community as their
sole advertising vehicle (Greer and Apple, 1991).
The infant formula industry has had a considerable adverse impact on breastfeeding
rates through some marketing tools, targeting women with direct advertising and with
the support of health providers. However public health agencies can work to contradict
this corporate influence by creative and insistent breastfeeding promotion, using the
same channels that have been leveraged by firms (Kaplan and Graff, 2008).
The International Code of Marketing of Breast Milk Substitutes
World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)
convened an international meeting in 1979 on infant and young child feeding. The
major outcome of this summit was the recommendation to adopt the International Code
of Marketing of Breast-milk Substitutes - “the Code” (Aguayo et al., 2003; Kaplan and
Graff, 2008).
In 1981 The World Health Organization (WHO) issued “The International Code of
Marketing of Breast Milk Substitutes” (Table 1) which outlined strict restrictions on
formula firms’ marketing strategies (Nelson et al., 2004; Schiff, 2006).

Table 1. Summary of the International Code Marketing of Breast Milk Substitutes (the Code)
adopted by the World Health Assembly in 1981 (resolution 34.22)
1. No advertising of all breast milk substitutes* to the public.
2. No free samples to mothers.
3. No promotion of products in health care facilities, including no free or low-cost formula.
4. No company representatives to contact mothers.
5. No gifts or personal samples to health workers. Health workers should never pass products
on to mothers.
6. No words or pictures idealizing artificial feeding, including pictures of infants, on the labels.
7. Information to health workers must be scientific and factual.
8. All information on artificial infant feeding, must explain the benefits and superiority of
breastfeeding, and the costs and hazards associated with artificial feeding.
9. Unsuitable products, such as sweetened condensed milk should not be promoted for babies.
10. Manufacturers and distributors should comply with the Code’s provision even if countries
have not acted to implement the Code.
* Breast milk substitutes include: infant formula, follow-up formula, feeding bottles, teats, baby food and
beverages.
Source: Nelson et al. (2004:351)

The Innocenti Declaration
In the 1970s and 1980s, increased attention to child survival heightened international
political awareness of the importance of early nutrition (Labbok, 2006).
The Innocenti Declaration was created by participants at the WHO/UNICEF
policymakers’ meeting on “Breastfeeding in the 1990s: A Global Initiative”. This event

was co-sponsored by the United States Agency for International Development (USAID)
and the Swedish International Development Authority (SIDA) and held at the Spedale
degli Innocenti, Florence, Italy, in 1990. Its goals included establishing national
breastfeeding coordinators and committees, ensuring proper maternity services
renewing efforts to implement the Code and enacting legislation protecting the
breastfeeding rights of working women (Nelson et al., 2004; Walker, 2007).
According to Labbok (2006), in 2002, with the development of the WHO/UNICEF
Global Strategy for Infant and Young Child Feeding, five tactical goals to those of the
Innocenti Declaration were added, as it can be observed below:
• Develop, implement and evaluate an effective policy on infant and young child
feeding, in the context of national policies and programmes for nutrition, child
and reproductive health, and poverty reduction;
• Guarantee that the health and other relevant sectors protect, promote and
support exclusive breastfeeding for six months and continued breastfeeding up
to two years of age, while providing women access to the support that they
need (in the family, community and workplace);
• Support opportunely, adequate, safe and suitable complementary feeding with
continued breastfeeding;
• Offer orientation on feeding infants and young children in difficult conditions;
• Consider what new legislation or other measures may be necessary, as part of
a broad policy on child feeding.
As a result of these numerous changes and efforts, exclusive breastfeeding increased
about 15% worldwide during the 1990s (Labbok, 2006). In some countries, the rate
doubled or tripled. It is also of interest that the quickest rate of increase occurred in
urban areas.
The Baby-Friendly Hospital Initiative
The Baby-Friendly Hospital Initiative (BFHI), created in 1991 by WHO and UNICEF, is
a call to action for maternities and hospitals, to become centres of excellence in
breastfeeding support (Nelson et al., 2004).
Maternity centres may become accredited when they demonstrate that they meet the
WHO/UNICEF criteria as a Baby-Friendly Hospital. Some of the criteria are: do not
accept free or low-cost breast milk substitutes, do not provide feeding bottles or
artificial nipples and has implemented the ten specific steps to support successful
breastfeeding (see Table 2) (Grizzard et al., 2006). Baby-Friendly hospitals can support
breastfeeding through education of health care providers in maternity and neonatal
services (Mikiel-Kostyra et al., 2005).

Table 2. The Ten Steps to Successful Breastfeeding, WHO/UNICEF
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff
2. Train all healthcare staff in skills necessary to implement this policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within a half-hour of birth
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be
separated from their infants
6. Give newborn infants no food or drink other than breast milk, unless medically indicated
7. Practice rooming-in—allow mothers and infants to remain together—24 h a day
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers to breastfeeding infants
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic
Source: Grizzard et al. (2006:248)

The kind of promotion in the BFHI aims to improve exclusive breastfeeding rates at
discharge, with exclusive breastfeeding during the first month being linked with
breastfeeding duration of longer than six months (Piper, 1996). To Gartner et al. (2005)
the key-practices to promote exclusive breastfeeding include the elimination of hospital
policies that discourage breastfeeding, such as unnecessary supplemental feeding,
infant formula discharge packs and formula discount coupons, separation of mother
and infant, and lack of adequate encouragement and support of breastfeeding.
At this point we can analyse some misconceptions regarding the BFHI. For example:
the idea that “some mothers will be forced to breastfeed”. The BFHI is not a coercive
approach to improving breastfeeding rates, duration, and exclusivity. Another idea is
that “babies cannot have bottles” or “the maternity centres cannot buy formula”. The
BFHI has no intention to make bottle-feeding mothers to feel guilty. But what it intends
to do is promote the idea that clinicians should be neutral on infant feeding (Grizzard et
al., 2006).
In what respects to benefits of the Baby-Friendly status, the hospitals can experience
numerous benefits. Many of the ten steps are easily adjustable as quality improvement
projects. Hospitals may benefit from cost restraint because increased breastfeeding
rates can have impact on many health care expenses.
Promotion of breastfeeding - Health promotion strategies
Based on Scandinavian experience, the European strategy for breastfeeding promotion
identifies a number of factors, which can contribute to an increase in breastfeeding,
including an improved availability of practical information on how to deal with
breastfeeding problems, mother-to-mother support, adequate maternity leave, changed
maternity ward practices, infant formula and healthy attitudes about the female body
(Helsing, 1990).

The European strategy for breastfeeding promotion has identified five intervention
aspects, including (i) knowledge, attitude and skills of health staff; (ii) maternity ward
routines; (iii) formation of breastfeeding mothers' support groups; (iv) support for
employed mothers who want to breastfeed; and (v) commercial pressure on health
workers and mothers (Helsing, 1990).
Findings/Conclusions
Highlights from the research conducted are described below. Usually mothers' infant-
feeding decisions were balanced between the benefits and costs of breastfeeding.
Breastfeeding was viewed as a way to realize mothers' goals to have a healthy baby
and enjoy a special time.
Breast milk was considered by most to provide better nutrition and better protection
from illness and a closer maternal-infant relation. For many women, the enjoyment they
expected to experience and the special time they associated with breastfeeding were
breastfeeding's most important benefits.
Some women worried that the additional time it takes to breastfeed a baby would
conflict with work and social life. They seem to be less worried that breastfeeding
would create embarrassing moments.
Other "costs" associated with breastfeeding were the pain associated with nursing,
changes nursing mothers would have to make in dietary and health practices, and
anxiety about their ability to produce the quality and quantity of breast milk needed to
meet their child's nutritional needs.
Sometimes women women's infant-feeding decisions reflect their lack of self-efficacy
as potential breast feeders and a lack of support from their chiefs, and some health
providers.
Women who had the intention of breastfeed indicated more perceived positive factors
and fewer barriers. The main findings were the significant positive influence of the
intervention on breastfeeding attitudes and perceptions as well as on exclusive
breastfeeding initiation and duration.
Marketing techniques can make an active role in the promotion of the benefits of the
breastfeeding, helping the health professionals in their jobs.

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