For many mothers-to-be, the decision whether and for how long to breastfeed looms large. In truth there are benefits, costs, and trade-offs to both breast- and formula-feeding. The problem is that most mothers in the United States do not end up breastfeeding exclusively, despite strong intentions: over three quarters of mothers want to exclusively breastfeed when their child is born, but less than one quarter are actually meeting that goal six month later.
Many breastfeeding promotion programs highlight the inherent benefits of breastfeeding – for instance, through prenatal education or motivational advertisements. Other types of programs, such as The Special Supplemental Nutrition Program for Women, Infants, and Children’s (better known as WIC) newly enhanced food package for breastfeeding mothers, try to tilt the economic cost-benefit scale in favor of breastfeeding. These strategies are in line with traditional economic theories – what economists call rational actor models – that seek to sway parents by increasing benefits or reducing costs of the desired behaviors.
And why shouldn’t programs do this? Parents want the best for their children, and are capable of tallying the pros and the cons. But the decision to breastfeed, like any decision, is not made in a vacuum. It occurs in context. Relevant contextual factors include judgment or support of family and friends; rules at birth hospitals and workplaces; complicated federal and state maternity leave policies; and a culture that associates breasts with sexuality instead of motherhood, to name a few. More to the point, the rules, environments, and cultures in a mother’s context may inhibit her from fully weighing costs and benefits, diluting the efficacy of traditional economic interventions like those described above, and leading to the intention-to-action gap we see in breastfeeding today.
In addition to contextual factors, cognitive shortcuts, common to all people, have the potential to interfere with fully analyzing costs and benefits. For instance, an established body of literature has shown that people strongly prefer immediate rewards to delayed rewards, and so they tend to see future costs or risks as “cheaper.” Here’s a concrete example: the immediate stress or fear that one may not be producing enough milk to support her child’s growth may seem more costly in relation to the increased likelihood of a child’s future illness, or the increased risk of breast cancer – both of which are strongly linked to formula feeding.
This so-called present bias may be especially insidious for parents with fewer resources. Studies have shown that financial instability, major life transitions, or lack of social support can deplete the mental energy required to thoroughly contemplate economic and healthcare decisions, reducing the likelihood that parents follow through on their breastfeeding intentions.
Cognitive shortcuts and contexts may help to explain why traditional economic incentives, while important, are not enough to support mothers to reach for the pump – not the formula – in their day-to-day lives. Tackling the root of these issues is no small task, but by leveraging our understanding of mothers’ contexts and biases, we can make small changes to existing programs and policies, or design new, behaviorally informed ones, to help more parents meet their breastfeeding goals.
Take the language that we use as breastfeeding researchers and advocates. We extol the virtues of breastfeeding in terms of health benefits or advantage over infant formula, calling it optimal nutrition that performs over and above what infant formula can provide. We are framing infant formula use as the default, and breastfeeding as something to be “opted-into.” How might breastfeeding attitudes or behaviors change in the United States if doctors, WIC counselors, and the media framed breastfeeding as the default?
There are other changes we can make, too, within existing services that may reap outsized rewards. Changes to WIC for example, could come in the form “light-touch” engagement strategies, like personalizing information, reminders, or appropriately timed self-affirmations, all of which have strong empirical support in other parenting programs. Intelligent scale-up of newer, behaviorally informed programs – like the app-based BFed program, or Lactation Advice through Texting Can Help (LATCH) intervention – would offer inexpensive ways to help mothers navigate the cognitive and contextual barriers that can affect breastfeeding decisions.
Breastfeeding promotion programs that assume decision-making from parents as independent of from contextual constraints are ignoring the biases, distractions, and stressors of scarcity that are the main drivers of infant feeding decisions. The low rate of exclusive breastfeeding is a public health problem that can (and should) be tackled via large-scale policy changes and “light touches” to increase uptake, engagement, and follow-through with programs that are already in place.
About the authors: Mackenzie Whipps is a 4th year doctoral student in the Psychology and Social Intervention (PSI) program in the department of Applied Psychology. Caroline Friedman Levy is a clinical psychologist and former Policy Fellow at the Department for Education in the UK. To read more about how behavioral insights can inform breastfeeding promotion, check out Mackenzie’s latest article with Drs. Hiro Yoshikawa and Erin Godfrey, out this week in Human Development. Photo courtesy of Mackenzie Whipps.