We often assume that mass media content can affect health decision-making. A wide literature, in fact, documents numerous mass media campaigns in the past century that were predicated on that idea . Actually detecting and documenting such media effects, however, has been a challenge less often met successfully. Moreover, some public health practitioners focus their attention on creating public service announcements and ignore the impact of other types of media content. There clearly is important work left to do in this arena.
Perhaps the most useful ideas as to how to locate and determine effects on health have arisen when researchers have stepped beyond the confines of a single, carefully-planned campaign evaluation to instead look at the impact of an array of media content on health beliefs and behavior [2–5]. For example, Southwell and colleagues looked at the relationship between news coverage and mammography seeking among U.S. women . In that work, there does appear to be a striking relationship between the presence of supportive or dissuasive news content and the proportion of women who obtained cancer screening. In light of these results, can we detect a similar relationship between media content and breastfeeding?
As we will discuss, the proportion of women breastfeeding has varied over recent decades. These fluctuations are vitally important from a medical perspective, as individuals' decisions to breastfeed (or not) carry significant consequences for infant health. Studies have shown that artificially fed infants experience higher risks of illness and allergies, and, on average, require more extensive dental care than breastfed infants [6–9]. Also, breastfeeding creates an emotional bond between mother and child . Considering these outcomes, it is important to understand what may influence mothers' decisions. Can trends in media content help to explain these vacillations? Before we answer that question, we first can look closer at recent patterns in the behavior.
Numerous studies on U. S. breastfeeding rates date back to at least the 1940s. Most research has centered on the fluctuation of breastfeeding rates in the twentieth century, illustrating how breastfeeding rates declined throughout much of the twentieth century, reached an all-time low in the early 1970s, and have tended to increase since that time [11–15].
Scholars have offered a number of explanations for the steep decline: increased hospitalization and anestheticization of new mothers, medical promotion of infant formula, and the use of feeding schedules all likely discouraged women from breastfeeding [16–18]. In addition to these factors, it is also probable that there is a cultural explanation worth considering, as the growing connection between infant formula and consumption and modernity – two important values, which discourage natural practices like breastfeeding, present in much mid- to late-20th century U.S. media content, for example – also may have promoted infant formula usage [18–20].
American breastfeeding rates experienced their record low in 1971, when an estimated twenty-one percent of the population breastfed their infants at birth . By this time, however, breastfeeding campaigns had started to develop. With the onset of the late 1960s and 1970s, some feminists and other advocates began campaigning for mothers to breastfeed their infants . These campaigns, together with a changing ideology about infant feeding, may have helped to reverse existing trends. Over the next decade, in fact, breastfeeding rates rose dramatically. By 1984, nearly sixty percent of new mothers chose to breastfeed their children .
Contemporary studies suggest that the decision to breastfeed continues to be a complex issue, shaped by a multitude of factors, such as a mother's prenatal care and the influence of her health professionals, her perception of the father's views on breastfeeding, and her fear of lack of an adequate milk supply for the infant [17, 21–23].
In the last thirty years, breastfeeding rates have generally increased, though there have been periods of slight decline. According to the 2001 Ross Laboratories Mothers Survey (RLMS), almost 70 percent of mother's initiated breastfeeding, which marks the highest breastfeeding initiation rate ever recorded in the United States [14, 24]. Mothers also have been nursing for longer periods of time. Results from the RLMS indicated that almost a third of mothers were breastfeeding their infants six months after birth [14, 24].
In sum, in past decades in the United States breastfeeding rates have fluctuated significantly. From the slow decline of breastfeeding in the early 1900s, the sharp descent of rates in the 1950s, and the growth of breastfeeding rates since this time, many external factors have been proposed as explanations for this variation, including changes in hospital resources and popular culture trends. Consideration of these various factors raises the question: what specifically might have been the role of exposure to media content?
For those who view reality as being socially constructed, media outlets can shape and reinforce dominant ideologies and convey these messages to a mass audience through systems of representation . Under this assumption, it is likely that media messages about infant feeding influences how a mother decides to feed her infant.
While journalists, advocates, and others shaping media content have certainly promoted breastfeeding at times, especially in the 1920s and the late 1970s, many commentators have suggested that mass media, specifically advertising, actually has often discouraged breastfeeding, by diffusing information about infant formula products, reinforcing many of the factors that discouraged breastfeeding, and promoting modernity and social status. Marchand stresses the importance of media in the adoption of new technology, stating that "inventions and their technological applications made a dynamic impact only when the great mass of people learn of their benefits, integrated them into their lives, and came to lust for more new products" . Through advertising, media not only alerts the public to new merchandise, but also teaches people why they need the product. By informing new parents of commercial milk substitutes and emphasizing their need for the product, media outlets likely encouraged the widespread adoption of breastfeeding alternatives.
Likewise, news organizations may have contributed to breastfeeding rate decline at times by perpetuating the myths that breastfeeding was dangerous. Often in the 20th century, a few cases of breastfeeding failures, such as infant starvation or the transmission of a mother's illness through her breast milk, would receive widespread publicity . Although the negative consequences of bottle feeding dramatically outweighed breastfeeding from the perspective of health professionals, mothers may have believed that infant formula was less risky and therefore chose to bottle feed their infants .
The sexualization of the breast in the 1900s, in which mass media outlets played no small role, also may have been a factor in explaining periodic declines in breastfeeding. Early in the century, numerous creams, mechanical devices, and medicinal remedies were developed to supposedly "enhance" breast size and appearance . Through advertising, women not only 'learned' of these specific products, but also may have learned that breast size and appearance were an important part of physical attractiveness . With less emphasis on the breast as a utility, more women viewed breastfeeding as archaic or obscene .
Advertising also has tended to promote the idea of "scientific motherhood," particularly since the 1950s. Apple suggests that brochures and advertisements in the 1950s commonly promoted the modernity of infant formula and associated the use of scientific developments with quality parenting . Many advertisements often conveyed the idea that a "good" mother does not simply rely on instincts but gathers knowledge about infant feeding and care . Likewise, advertisements often promoted infant formula as an "elite" method of feeding one's infant, associating bottle feeding with higher class and modernity . From these advertisements, mothers may have learned that if they did not use infant formula, society would consider them to be old-fashioned, uneducated, and perhaps of a lower class.
Contemporary research indicates that the topic of infant feeding is pervasive in media content around the world and yet is not discussed consistently. In a study of British media, Henderson and colleagues found numerous references to infant feeding on television and in newspaper articles . More importantly, they found that media content often presented bottle feeding as easier and as more common than breastfeeding, which was depicted as difficult and more prevalent among the upper middle class and celebrities . In a different part of the world, Henderson determined that discourse in Australian media content both promoted breastfeeding as the best infant feeding choice, while at the same time often suggested that breastfeeding is difficult and not conducive to contemporary lifestyles . Studies also have suggested that media content can play a positive role in shaping infant feeding decisions. Research performed by Arora and colleagues indicated that roughly 90 percent of surveyed mothers who breastfed reported that books, magazines, and television positively influenced their decisions to breastfeed .
The purpose of this study is to examine if a relationship between media content on infant feeding and breastfeeding rates exists. We present here results from a content analysis of the advertisements and articles in Parents' Magazine, a popular women's publication, which has offered information on health and child development since its inception in 1926 and explore whether those results predict breastfeeding outcomes (for the three decades of annual data available, as discussed below) .
We predict the promotion of infant formula usage will negatively affect the prevalence of breastfeeding. Conversely, breastfeeding support in the media should correlate with an increase in breastfeeding rates. More specifically, the following hypotheses guided this study.
Hypothesis 1 (H1)
The frequency of hand feeding advertisements in Parents' Magazine from 1971 to 1999 will negatively correlate with changes in breastfeeding reported the following year.
Hypothesis 2 (H2)
The frequency of articles promoting hand feeding in Parents' Magazine from 1971 to 1999 will negatively correlate with subsequent changes in reported breastfeeding.
Hypothesis 3 (H3)
The frequency of articles supporting breastfeeding in Parents' Magazine from 1971 to 1999 should positively correlate with subsequent changes in reported breastfeeding.
We focus here on the role played by hand feeding advertisements and articles promoting either hand feeding or breastfeeding. Wolf discusses how the term "hand-feeding," meaning the provision of alternative food to breast milk to infants, was used by middle-class mothers as early as the late 1800s . We continue the usage here, though acknowledge that debate exists as to the most appropriate phrase. Our primary focus on hand feeding advertisements and decision not to also assess the potential impact of advertisements that explicitly promote breastfeeding were driven by the expectation that very few of the advertisements placed in parenting magazines during this time period would promote breastfeeding. (Analysis using the methods described below confirmed this expectation, as no breastfeeding advertisements were found).