1

SOCIAL MARKETING SUCKS
MARKETING’S ROLE IN PROMOTING BREASTFEEDING









ABSTRACT
In recent years, researchers and health care professionals have shown an
increasing interest in the health gain associated with breastfeeding and in the
problems arising from bottle feeding. It seems that there has been an ideological
shift towards the belief that breastfeeding is beneficial and necessary.
The purpose of this paper is to describe a social marketing programme aiming to
foster breastfeeding adoption and prevalence. Besides the impact on mothers and
children health, breastfeeding has an important economic impact. It is a socially
important theme in the field of marketing, in which there is little research done.

KEY WORDS
Breastfeeding, Social marketing, Public health, Consumer behaviour, Promotion

2
1. INTRODUCTION
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).
The infant formula industry has had a considerable adverse impact on breastfeeding rates1
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).
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.
Given this scenario some researchers have been defending the prevalence of breastfeeding
practices. This paper explores the effectiveness of social marketing as a tool to increment the
breastfeeding rates. In this scope, some strategies could be used to convince specially the
mothers.
This article aims to address some of the issues surrounding social marketing and promotion of
breastfeeding programmes. After the brief contextualization presented above, some theoretical
considerations about social marketing will be done, as well as some aspects on the design of
social marketing programmes. The discussion on this problematic will lead us to next point of
the paper: the breastfeeding, and its promotion, in the context of public health. The main
methodological aspects related to the investigation will be presented in fourth section, and then
the results will be discussed. Finally, the last section discusses some practical implications and
presents some conclusions.

2. SOCIAL MARKETING AND THE CHANGING BEHAVIOURS
2.1. Concept and scope
To Domegan (2007:103), “social marketing is, broadly speaking, the application of marketing
principles to social issues and is best known for its use in campaigns related to public health
and the environment”. Social issues where educational and legal interventions have failed seem
to be the most attractive themes to social marketing marketers.
Social marketing was first discussed by Kotler and Zaltman in 1971. This was the first time the
term was used. They defined social marketing as "the design, implementation and control of
programs calculated to influence the acceptability of social ideas and involving considerations

1 Epidemiological studies in the 1970s identified the bottle with commercial formula as the main cause of the
declining rate of breastfeeding (Zetterström, 1999).

3
of product planning, pricing, communication, distribution and marketing research” (Kotler and
Zaltman, 1971:5).The authors referred that this approach could be particularly useful in the
application of marketing to the solution of social and health problems.
According to Domegan (2007), the conceptually modern view of social marketing has matured
and now fixes its sphere of influence roughly the exchange process of voluntary behavioural
change. More recent discussions within the literature (e.g. Andreasen, 1995; 2002; Hastings,
2003; Kotler et al., 2002,) corroborate the conceptual movement towards the market with
relational approach. Currently the most established meanings of social marketing manifesting
this view have been presented by
- Andreasen (1995:296): “the application of commercial marketing technologies to the
analysis, planning, execution and evaluation of programs designed to influence the
voluntary behaviour of target audiences in order to improve their personal welfare and
that of their society”;
- Hastings (2003:12): “social marketing’s most important feature is that it takes learning
from commerce such as consumer orientation, mutually beneficial exchange, the need
to focus on behaviour change and address the context as well as the individual”;
- Kotler et al. (2002:5): “is the use of marketing principles and techniques to influence a
target audience to voluntarily accept, reject, modify or abandon a behaviour for the
benefit of individual, groups or society as a whole”.
Social marketers try to solve social problems by changing deep and long standing beliefs and
related behaviours that have a negative effect on consumer well-being (Kotler and Andreasen,
1996).
The extension of the marketing concept, jointly with a change in public health policy towards
disease prevention, began to pave the way for the development of social marketing. During the
1960s, commercial marketing techniques began to be applied to health education campaigns in
developing countries (Ling et al. 1992).
However, it is important to note that health problems have a social, as well as an individual,
dimension. So social marketing faces a great challenge which is to influence the behaviour, not
only of the individual citizen, but also of policy makers and significant interest groups
(MacFadyen, Stead and Hastings, 1999).
According to Kotler and Zaltman (1971), social marketing is a framework or structure that
draws from many other bodies of knowledge (e.g. psychology, sociology, anthropology,
communications) to understand how to influence people’s behaviour. Like conventional
marketing, social marketing offers a rational planning process involving consumer oriented
research, marketing analysis, market segmentation, objective definition and the identification of
strategies. It is based on the voluntary exchange of costs and benefits between the parts (Kotler
and Zaltman, 1971). To make easy voluntary exchanges, social marketers have to offer
individuals something that they really want (MacFadyen, Stead and Hastings, 1999).
Infant feeding could be described as a social marketing issue. The topic presents two relevant
challenges: (i) it is necessary to market to several publics (health care providers, parents, young
women, etc.); and (ii) it is a traditional conflict between the breast milk substitutes (formula)
and the breastfeeding.
In what concerns to the first challenge Giles et al. (2007) refer that although recent efforts to
promote breastfeeding have resulted in much progress in many areas, evidence is now
accumulating to suggest that breastfeeding promotion should be aimed at the entire population
and should be undertaken in schools. The school system can play an important role in health
promotion and should expose all students to the theme of breastfeeding through its health
classes.
In addition to explain the interest in the study “breast versus bottle decision”, the marketers
found a gap between what both government and medical staff have propose as objectives, and

4
what really happens (Oglethorpe, 1995). Why this gap happens once there are well recognized
benefits of breast over bottle, and most researchers agree that the majority of mothers are able to
breastfeed?
Social marketing approaches are a relevant element of health promotion. Therefore most authors
agree that social marketing can be a toll to reduce health disparities (Williams and Kumanyika,
2002), and to promote healthy habits and practices. In this sense, a question seems to be
pertinent: how it can be used effectively? This will depend on how one defines social marketing
aims and targets.

2.2. Designing a social marketing programme of breastfeeding promotion
Marketing managers should be well aware of theories of behaviour change, but the conception
and implementation of social marketing programmes is rarely driven by theoretical models.
However, there are some advantages of having in mind such theories, that could be useful, and a
kind of mental roadmap or social science model, which can contribute to increase the
probability of success of the programme (Andreasen, 1995).
The improvement of breastfeeding rates is possible with the application of a social marketing
model. For example in United States was implemented a programme named The National WIC
(Women, Infants and Children) Breastfeeding Promotion Program to promote breastfeeding.
Lindenberger and Bryant (2000) concluded that social marketing offers public health
professionals an effective approach for designing and implementing this kind of projects.
As we could notice social marketing has become a widely accepted approach to solving public
health problems (e.g. reduce risk behaviours, promote contraceptive use, preventing youth from
smoking, increase the use of public health services, and so on). When we think in breastfeeding,
we have to think in provide support, education and promotion. So, some marketing tolls can be
applied.
A social marketing campaign or programme contains the following elements: a consumer
orientation, an exchange and a long-term planning (Andreasen, 1995; MacFadyen, Stead and
Hastings, 1999).
According to Andreasen (1995) the social marketing process is an iterative process that consists
of six steps:
(i) Initial planning, background analyses and formative research;
(ii) Strategy development and determination of the mission, objectives, and core strategy;
(iii) Program development;
(iv) Pre-testing of key program components and materials;
(v) Implementation;
(vi) Monitoring and evaluation.
Using the model describe above we will try to describe a Portuguese programme that is being
implemented in the Hospital Centre of Beira Interior (HCBI). We will also try to show that the
social marketing techniques can help in the promotion of breastfeeding.
At this point, and in this paper, we will just describe the first step proposed by Andreasen
(1995). However, a short explanation about the other steps will be here provided.
To develop the strategy, formative research results should be used to develop a marketing plan
to guide the development, implementation, and tracking of the project. The marketing plan can
be organized around marketing's conceptual framework of the 4 Ps (product, price, place, and
promotion) with an emphasis on positioning and defining breastfeeding. The programme
development and structuring phase involve the development and revision of all campaign
materials and strategies. An advertising agency can be contacted to design public information

5
messages and prepare consumer education materials. In the pretesting phase, program strategies,
campaign messages and materials, and other products are pretested and revised. Although
coordination is important for any programme, social marketing projects implementation
demands careful sequencing of a wide variety of activities: professional training, materials
distribution, public information and public relations. Usually, in the monitoring and evaluation
phase, reports are prepared in order to identify problems and opportunities and also assess its
impacts (Lindenberger and Bryant, 2000; Andreasen, 1995).
In what concerns to initial planning and research it is necessary to collect consumer information
to identify the target and the factors that had to be addressed in order to encourage it to
breastfeed. The primary target population for the HCBI breastfeeding programme was
comprised of pregnant woman. These women will give birth to their children in the hospital.
During their pregnancy the medical team will try to provide all the information about the
breastfeeding.
In this hospital pregnant women and their partners are encouraged to attend a formal series of
childbirth education classes. These classes are believed to provide an excellent opportunity for
women to obtain specific information about labour, pain relief, delivery, normal infant care,
postpartum adjustment, and breastfeeding.
Despite increasing recognition of their importance, little is currently known about the utilization
and outcomes of these childbirth education classes. But, for example, Lu et al. (2001) in their
study found that mothers who had attended childbirth classes were 75% more likely to initiate
breastfeeding than those who did not.
3. BREASTFEEDING IN THE CONTEXT OF PUBLIC HEALTH
3.1. Concept and evolution
Liddell (2005) found some texts (e.g. Opúsculo Humanitário and La Donna) that portray
breastfeeding, and indeed women’s wider maternal responsibilities, as every mother’s patriotic
duty to the nation. This was a common theme in anti-wet-nursing discourse in Brazil and
France. The major concern was to reduce child mortality rates at a time when industrial
capitalist societies required an ever greater labour force to develop and compete. Nevertheless,
many individuals looked beyond simple demographic factors. A mother’s duty was to raise sons
who were both physically and ethically health.
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).
Nelson et al. (2004) refer that in the 1970s, several reasons explaining the decline of
breastfeeding were identified. These reasons were mainly related with the urbanization’s
phenomenon and the marketing of commercial formulae. On the other side, the promotion by
the slogan “breast is best” was not particularly successful in developing countries and the
predominance of exclusive breastfeeding stilled low. At this time the rates of breastfeeding
varied widely and according to WHO’s global data bank on breastfeeding, with data from 94
countries, an estimated 35% of infants were exclusively breastfed between birth and 4 months
of age.
In recent years, researchers and health professionals have shown an increasing interest in the
health gain associated with breastfeeding and in the problems arising from bottle feeding. It
seems that there has been an ideological shift towards the belief that breastfeeding is beneficial
and necessary.
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.

6
Exclusive breastfeeding increases the benefits of health, growth and development of infants
(Finch and Daniel, 2002; Chatterji and Frick, 2005; Kaplan and Graff, 2008; Leavitt et al.
2008); while the use of artificial milk is associated with some disadvantages for the infant and
mother (Kramer, 1998). Exclusive breastfeeding and continued breastfeeding for two years is
associated with reduction in underweight and is an exceptional source of high quality calories
for energy. Breastfeeding provides a food, serving as low-cost, with high quality, locally
“produced” and secure for the child (Labbok, 2006).
Breastfeeding helps keep away from many health and emotional problems for the mother, this
is, the mother who does not breastfeed has slower recuperation post-delivery, increased stress
and blood loss postpartum, less vital uterine involution, early return to fertility and increased
risk of cancer of the breast and ovaries. Immediate postpartum breastfeeding seems to increase
the relation between mother and child (Gartner et al., 2005; Labbok, 2006).
To Rhodes et al. (2008), breastfeeding is a health behaviour with immediate and long-term
health benefits for the mother and her child. This act is associated with reduced risk for the most
common childhood infections (e.g. otitis, respiratory infections, gastrointestinal illness) as well
as reduced risk for many chronic diseases (e.g. allergies, asthma, diabetes).
Galler et al. (2006) refer that some researchers, considering the psychosocial aspects of
breastfeeding and reasons for its early cessation, have recognized the important role of maternal
perceptions and views about the benefits and social acceptance of breastfeeding. Nevertheless,
several variables seen to affect negatively breastfeeding behaviour. Alexy and Carter-Martin
(1994) point the lack of education and support, the embarrassment, the returning to work or
school quickly and the distribution of milk substitutes’ free samples.

3.2. The International Code of Marketing of Breast Milk Substitutes
WHO and the 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 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)

7
The Code is a set of marketing recommendations, not a set of prohibitions for the manufacture
and sale of infant formula. It recognizes that breastfeeding is a health issue, not a commercial
one, and that it needs legal protection. The Code role is a tool to limit unethical marketing
practices, false advertising, and the complicity of the health care system in persuading a mother
to replace her milk with a commercial substitute. In 1981, the United States was the only
country to vote against the adoption of the Code, but in 1994 it joined in the consensus in
endorsing the Code and subsequent resolutions to that point. The scope of the Code covers
products that are marketed in a way that encourages bottle-feeding (Labbok, 2006).
By the 1996 World Health Assembly meeting all 191 member states had affirmed their support
for the code and the implementation of relevant resolutions. By 1997, 17 countries had adopted
all or substantially all of the code's provisions as legal requirements. This global adoption of the
code represents the development of an international consensus (Taylor, 1998).
The Code is primarily aimed at governments. Governments are meant to use the Code as a
“minimum requirement” and implement it, either as a law or as a voluntary measure (Nelson et
al., 2004)
Marketing practices tend to differ in different countries depending on the attention of the
government, professionals and consumers, but it should be focused that the Code should be
followed by firms similarly in all countries (Nelson et al., 2004; Taylor, 1998)
Although the importance of the code’s worldwide adoption some violations were detected.
According to Taylor (1998), the rate of the violations occurring shows that 16 years after the
World Health Assembly adopted the code, its requirements are still unmet. There is little
optimism that breastfeeding will be protected from commercial pressure, unless there is a
commitment to implement and supervise the code nationally. Governmental and
non­governmental agencies should check the prevalence of code violations.

3.3. Promotion of breastfeeding - health promotion strategies
Based on Scandinavian experience, the European strategy for breastfeeding promotion
identified 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).
With increasing entry of women into the workforce, the promotion of breastfeeding often
conflicts with the practical imperatives faced by many mothers. It is proved that legislation
which improves both maternity leave and revises the milk token scheme, together with work
lays which promotes more flexible working hours for mothers and better nursery facilities in the
workplace is very likely to have a main influence on breastfeeding rates (Campbell and Jones,
1996).
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).
(i) Knowledge, attitudes and skills of health staff
Health staff providing breastfeeding advice to mothers includes hospital and community
midwives, health visitors and general practitioners. Given the disparity in breastfeeding
knowledge and practice, sometimes breastfeeding mothers' complain about conflicting advice
(Campbell and Jones, 1996). Nor do paediatric and obstetric medical staff have adequate
educational or practical experience to prepare them to be able to give information and advice on
breastfeeding (Freed et al., 1992). Postgraduate education for paediatricians should incorporate
comprehensive education on breastfeeding.

8
(ii) Maternity ward routines
There is indication that the non-verbal modelling provided by routine hospital practices has
more influence on breastfeeding outcome than what is actually said to mothers. Some initiatives
have shown that an educational programme alone without subsequent reinforcement may have
little impact in reducing incorrect practices (Iker and Morgan, 1992).
(iii) Formation of breastfeeding mothers' support groups
Providing timely advice and support to breastfeeding mothers is essential for successful
breastfeeding. This is becoming even more important with the promotion of aspects considered
to reduce the mean period of maternity hospital stay.
(iv) Support for employed mothers who want to breastfeed
Until employers develop maternity policies which do not discourage breastfeeding it will be
hard for most employed women to continue breastfeeding over the first three months. There are
few published data on the effectiveness of changes in government legislation for national
breastfeeding practices (Helsing, 1990).
Employed mothers who choose to continue breastfeeding face problems such as a lack of space,
time, and employer support for milk expression at work (Dunn et al., 2004). Working mothers
confront these issues at a time when they also face life changes that all postpartum women,
usually face, such as physical recovery from childbirth, postpartum depression, changes in
marital relationships and role identities, and infant health problems (McGovern et al., 1997;
Chatterji and Frick, 2005).
(v) Commercial pressure on health workers and mothers
The WHO code on marketing of breast milk substitutes refers that mothers should be given
neither literature which contains advertising nor free samples of formula milk before discharge
from hospital (Campbell and Jones, 1996). Although approved by governments of most
industrialized countries this code of practice is not universally implemented (Aguayo et al.,
2003; Taylor 1998). Thus, studies to evaluate the impact of public campaigns to promote
breastfeeding and those of health education within health and social programmes should be
done (Campbell and Jones, 1996).

4. METHODOLOGY
In order to carry out the study, a team composed by medical staff of the obstetric department of
the Hospital Centre of Beira Interior (HCBI) and some marketing researchers of the University
of Beira Interior, that all together defined some research objectives:
1. Identify women's perceptions of breastfeeding;
2. Identify effective information channels and persons for promoting breastfeeding;
3. Evaluate the knowledge about the right breastfeeding techniques;
4. Identify the factors that influence women's infant-feeding decisions;
5. Identify the women's difficulties at the time of breastfeed;
6. Identify the myths associated with the breastfeeding;
7. Evaluate the obstetric service and the patients’ satisfaction.
Due to space limitations in this paper, only research objectives one through three will be
analysed.
For this study, the model of data collection was a survey questionnaire with several groups of
questions, some of them gathered from interviews and questionnaires adapted from the existing
instruments. Information about knowledge, perceptions, attitudes, breastfeeding intentions,

9
myths, satisfaction and demographic characteristics was requested. The final questionnaire is
based on the existing theoretical and empirical literature about the topic and the experience and
perception of the medical personal.
Questionnaires were administered in the hospital, during the time that the women were in
convalescence, after the child’s birth, with permission from the service director and with the
collaboration of the nurses. The final sample was composed of 79 women.
The data collected will be analysed and interpreted using the statistical software SPSS 16.0
(Statistical Package for Social Sciences) in the next section. We use mainly descriptive statistics
and cross tabulation to analyse the information.

5. RESULTS
Regarding perceptions about breastfeeding, women were asked about the time they considered
adequate to start breastfeeding. In some cultures, it is still believed that only after some hours,
or even days, breastfeeding is adequate, which is contrary to World Health Organisation’s
recommendations (WHO, 2009).
TABLE 2
When should breastfeeding start

Frequency Percent Valid Percent
Cumulative
Percent
Valid Within the first hour of life 70 88,6 98,6 98,6
After the first hour of life 1 1,3 1,4 100,0
Total 71 89,9 100,0
Missing System 8 10,1
Total 79 100,0

As shown in TABLE 2, almost every mother answered within the first hour of life.
Another questions has to do with breastfeeding duration. WHO (2009)
recommendations point to a minimum of six months of exclusive lactation, and a
minimum of twenty four months of breastfeeding.

Results on TABLE 3 show that the mean perceptions are lower than WHO
recommendations. Exclusive breastfeeding perception has a mode of 4 moths (which is
the duration of parental leave in Portugal), lower than the 6 months recommendation.
As for breastfeeding total duration, the mode is the recommended 24 months, but the
TABLE 3
Statistics of perceptions on breastfeeding duration
How many months
should
breastfeeding be
exclusive?
How many months
should your child
be breastfed?
N
Valid 43 27
Missing 36 52
Mean 5,19 13,19
Mode 4 24
Std. Deviation 1,98 7,77

10
mean is still very lower than that value. Standard deviation is almost 8 months, which
indicates that there is a considerable number of mothers who is well informed, but an
also considerable group of mothers is not. These results are reinforced by the reulst shon
on TABLE 4 and TABLE 5.
TABLE 4
How many months should breastfeeding be exclusive?

Frequency Percent Valid Percent
Cumulative
Percent
Valid 3 3 3,8 7,0 7,0
4 20 25,3 46,5 53,5
5 3 3,8 7,0 60,5
6 12 15,2 27,9 88,4
7 2 2,5 4,7 93,0
9 1 1,3 2,3 95,3
12 2 2,5 4,7 100,0
Total 43 54,4 100,0
Missing System 36 45,6
Total 79 100,0

TABLE 5
How many months should your child be breastfed?

Frequency Percent Valid Percent
Cumulative
Percent
Valid 1 1 1,3 3,7 3,7
4 2 2,5 7,4 11,1
5 1 1,3 3,7 14,8
6 4 5,1 14,8 29,6
7 1 1,3 3,7 33,3
8 1 1,3 3,7 37,0
9 1 1,3 3,7 40,7
12 6 7,6 22,2 63,0
18 3 3,8 11,1 74,1
24 7 8,9 25,9 100,0
Total 27 34,2 100,0
Missing System 52 65,8
Total 79 100,0
As for the identification of prescribers of breastfeeding behaviours, figurE 1, shows that
nurses are the have the major share when informing and leading mothers into
breastfeeding behaviour.

11
FIGURE 1
Who informed the mother about breastfeeding
Who informed the mother about breastfeeding
60%
8%
3%
3%
9%
17%
Nurse
Family doctor
Paediatric doctor
Obstetric doctor
Family and friends
Books and Magazines


The information that is passed to the mothers has influence on their decision. WHO
(2009) states that breastfeeding has several advantages to mother and baby. There is still
lots of information that is not passed to the mothers, as can be seen on Table 6.
TABLE 6
Information contents
Mother was informed about… No Yes Total
breastfeeding advantages to the mothers
count 25 54 79
% 31.6% 68.4% 100%
breastfeeding advantages to the babies
count 22 57 79
% 27.8% 72.2% 100%
breastfeeding advantages to the family
count 65 14 79
% 82.3% 17.7% 100%
breastfeeding advantages to the
environment
count 75 4 79
% 94.9% 5.1% 100%
human milk characteristics
count 43 36 79
% 54.4% 45.6% 100%
the risks of the early start of artificial
milk
count 52 27 79
% 65.8% 34.2% 100%
anatomy and physiology of
breastfeeding
count 56 23 79
% 70.9% 29.1% 100%
breastfeeding technique
count 44 35 79
% 55.7% 44.3% 100%
manual extraction of milk
count 53 26 79
% 67.1% 32.9% 100%
success factors in breastfeeding
count 53 26 79
% 67.1% 32.9% 100%
how to cope with breastfeeding hurdles
count 48 31 79
% 60.8% 39.2% 100%

12
As for breastfeeding techniques mothers were asked if they gave a dummy to their child
during their stay in the hospital (first 48 hours of life).
FIGURE 2
Did you give a pacifier/dummy to the child while in the hospital?

Figure figurE 2 shows that almost three quarters of the mothers offered pacifiers to their
children, even if many of them refused the dummy (Figure figurE 3).

FIGURE 3
Does your child use pacifier/dummy now?



6. 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.

13
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.
Nurses are the most important information vehicle to mothers, and should be targeted in the
Social Marketing programme to be developed to promote breastfeeding incidence and
prevalence.
There is still much to do in the amount and diversity of information to be passed to mothers.
Results point out that there is an important effort to be done in what concerns to breastfeeding
promotion and information.
However, it is necessary to analyse more deeply the application of the consumer behaviour
perspective to better understand the breastfeeding decision which, although private, has relevant
public consequences in terms of public health. For this it is necessary to mainly discuss the
exchange process, the satisfaction and the public policy. Another question is related with the
methodological challenges inherent in the research of infant feeding, once that the results seem
to point to a structural relationship between a set of multi-dimensional variables.
It has been suggested that attitudes towards breastfeeding are influenced by the conflicting
needs of the mother and the infant and that mothers may be more motivated to breastfeed when
they find it to be an advantage for themselves. Programmes for the promotion of breastfeeding
thus have been criticised for paying attention only to the needs of the infants and neglecting the
reactions of the mothers. If breastfeeding is promoted as a duty, inability to do so will create
guilt feelings. So, some research is necessary in order to understand these guilt feelings.
As a future study it will be tried to find if the women who receive breastfeeding education are
breastfeeding their child at six months postpartum.
Finally, it is our opinion that efforts to make breastfeeding the norm can succeed, but they must
become a public health priority. These efforts count on effective partnership among
governmental and non-governmental agencies, hospitals and healthcare providers, health
professional bodies, community-based organizations, employers and trade unions. The
partnership must issue clear, consistent messages that not only promote the benefits of
breastfeeding but also illuminate the negative effects of formula feeding.

REFERENCES
Aguayo V, Ross J, Kanon S, Ouedraogo A (2003) Monitoring compliance with the International
Code of Marketing of Breastmilk Substitutes in West Africa: multisite cross sectional survey in
Togo and Burkina Faso. BMJ 326:18 Jan.
Alexy B, Carter-Martin A (1994) Breastfeeding: perceived barriers and benefits/enhancers in a
rural and urban setting. Public Health Nurs 11:214-218.
Andreasen AR (2002) Marketing social change in the social marketplace. J Public Policy Mark
21(1):3-13.
Andreasen AR (1995) Marketing social change: changing behaviour to promote health, social,
development, and the environment. Jossey-Bass Publications, San Francisco.
Campbell H, Jones I (1996) Promoting breastfeeding: a view of the current position and a
proposed agenda for action in Scotland. J Public Health Med 18(4):406-414.
Chatterji P, Frick K (2005) Does returning to work after childbirth affect breastfeeding
practices?. Rev Econ Household 3:315-335.
Domegan C (2007) The use of social marketing for science outreach activities in Ireland. Ir J
Manag 28(1):103-125.

14
Dunn BF, Zavela, KJ, Cline AD, Cost PA (2004) Breastfeeding practices in Colorado
businesses. J Hum Lact 20:170-177.
Finch C, Daniel, E (2002) Breastfeeding education program with incentives increases exclusive
breastfeeding among urban WIC participants. J Am Diet Assoc 102(7):981-984
Freed GL, Jones, TM, Fraley, JK (1992) Attitudes and education of pediatric house staff
concerning breastfeeding. South Med J 85:483-485.
Galler J, Harrison R, Ramsey F, Chawla S, Taylor J (2006) Postpartum feeding attitudes,
maternal depression, and breastfeeding in Barbados. Infant Behav Dev, 29:189-203.
Gartner LM, Morton J, Lawrence RA et al. (Section on Breastfeeding) (2005) Breastfeeding
and the use of human milk. Pediatrics 115(2):496-506.
Giles M, Connor S, McClenahan C, Mallett J, Stewart-Knox B, Wright M (2007) Measuring
young people’s attitudes to breastfeeding using the Theory of Planned Behaviour. J Public
Health 29(1):17-26.
Hassan L, Walsh G, Shiu E, Hastings G, Harri, F (2007) Modeling persuasion in social
advertising: a study of responsible thinking in eight Eastern EU (European Union) members
states. Journal Advert 36(2):15-31.
Hastings G (2003) Relational paradigms in social marketing. J Macromark 23(1):6-13.
Helsing E (1990) Supporting breastfeeding: what governments and health workers can do -
European experiences. Int J Gynecol Obstet 31(Suppl 1):69-76.
Iker CE, Morgan J (1992) Supplementation of breastfed infants: does continuing education for
nurses make a difference?. J Hum Lact 8:131-135.
Kaplan DL, Graff, KM (2008) Marketing breastfeeding - reversing corporate influence on infant
feeding practices. J Urban Health: DOI:10.1007/s11524-008-9279-6
Kotler P, Roberto EL, Lee N (2002) Social marketing: improving the quality of life 2nd edn.
Sage, Thousand Oaks (California).
Kotler P, Andreasen AR (1996) Strategic Marketing for Non-profit Organizations 5th edn.
Pearson Education/Prentice-Hall, Upper Saddle River, New Jersey.
Kotler P, Zaltman G (1971) Social marketing: an approach to planned social change. J Mark
35:3-12.
Kramer MS (1998) Infant feeding, infection and public health. Pediatrics 81:164-165.
Labbok M (2006) Maternal and newborn care breastfeeding: a woman’s reproductive right. Int J
Gynecol Obstet 94:277-286.
Leavitt G, Silma M, Nerian O, Lourdes G (2008) Knowledge about breastfeeding among a
group of primary care physicians and residents in Puerto Rico. J Com Health: DOI
10.1007/s10900-008-9122-8
Liddell C (2005) Nature, nurture and nation: Nísia Floresta’s engagement in the breast-feeding
debate in Brazil and France. Fem Rev 79:69–82.
Lindenberger JH, Bryant, CA (2000) Promoting breastfeeding in the WIC program: a social
marketing case study. Am J Health Behav 24(1):53-61.
Lu MC, Lange, LO, Slusser W, Hamilton J, Halfon, N (2001) Provider encouragement of
breastfeeding: evidence from a national survey. Obstet Gynecol 97:290-295.
MacFadyen L, Stead M, Hastings G (1999) A synopsis of social marketing,
http://www.ism.stir.ac.uk/pdf_docs/social_marketing.pdf. Accessed 10 Feb 2009.

15
McGovern P, Dowd B, Gjerdingen D, Moscovice I, Kochevar L, Lohman W (1997) Time off
work and the postpartum health of employed women. Med Care 35(5):507-521.
Nelson E, Chan C, Yu C (2004) Breast milk substitutes in Hong Kong. J Paediatr Child Health
40:350-352.
Oglethorpe J (1995) Infant feeding as a social marketing issue: a review. J Consum Pol
18(2/3):293-314.
Rhodes K, Hellerstedt W, Davey C, Pirie P, Daly K (2008) American Indian breastfeeding
attitudes and practices in Minnesota. Mat Child Health J 12:S46–S54.
Rosenberg K, Eastham C, Kasehagen L, Sandoval A (2008) Marketing infant formula through
hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public
Health 98(2):290-295.
Schiff L (2006) Breastfeeding makes for better health. Mt Sinai J Med 73(2):571-572.
WHO (2009), Fact File – 10 facts on Breastfeeding,
http://www.who.int/features/factfiles/breastfeeding/facts/en/index.html, Accessed 5th
March 2009
Williams J, Kumanyika S (2002) Is social marketing an effective tool to reduce health
disparities?. Social Mktg Q 8(4):14-31.
Zetterström R (1999) Breastfeeding and infant–mother interaction. Acta Paediatr Suppl 430:1-6.