Abstract
Abstract
Objective:
This study surveyed the prevalence of bottle versus breastfeeding graphic images on products marketed for pregnant mothers and young children available for purchase in national chain stores.
Study Design and Methods:
This was a product survey/content analysis. Eighteen national chain stores located in a 10-mile radius of Charlottesville, VA were visited. In total, 2,670 individual items in 11 categories of baby shower and baby gift merchandise (shower invitations, greeting cards, gift wrap, shower decorations, baby dolls, baby books, infant clothing, bibs, nursery decorations, baby blankets, and disposable diapers) were assessed. The main outcome measures were prevalences of baby bottle and breastfeeding graphic images.
Results:
Baby bottle images were found on products in eight of the 11 categories of items surveyed. Thirty-five percent of baby dolls were marketed with a baby bottle. The prevalence of bottle images on items in all other categories, however, was low. Of the 2,670 items surveyed, none contained a breastfeeding image.
Conclusions:
The low prevalence of baby bottle images on commonly purchased baby gift and baby shower items is encouraging. However, the absence of breastfeeding images and the relatively high prevalence of baby dolls marketed with a baby bottle demonstrate that breastfeeding is not portrayed as the physiologic norm on these products. Product designers should explore ways to promote breastfeeding, consumers should make informed choices in product selection, and advocacy groups should promote guidelines for these products.
Introduction
Social support and perceived cultural norms are important determinants of mothers' decisions to initiate and continue breastfeeding. The fact that the majority of mothers in the United States initiate breastfeeding but do not continue to follow the AAP recommendations suggests that, although women desire to breastfeed their children, they struggle to continue to do so. A retrospective study of 150 women found that breastfeeding for at least 6 months was positively associated with the encouragement of others and belonging to an environment where breastfeeding is regarded as the norm. 4 Another study found that women believed their choice was greatly shaped by the opinions of family and friends. 5
The media is a powerful instrument of social norms whose influence on health behavior is well documented. 6 A study in the United Kingdom analyzed televised media and the press and found that positive information about breastfeeding is rarely presented. These authors concluded that the media portrays breastfeeding as problematic, funny, and embarrassing. In contrast, bottle feeding is socially integrated, highly visible, unproblematic, and associated with “ordinary” families. 6 A 2010 study found that 56% of pregnancy and early parenting magazines contained advertisements for infant formula, with an average of 2.5 ads per issue. The majority of these advertisements contained at least one positive health statement. Women with uncertain breastfeeding intentions exposed to these ads were less likely to initiate breastfeeding and more likely to terminate breastfeeding early. 7
Direct marketing by manufacturers of infant formula also impacts breastfeeding practices. A Cochrane meta-analysis of nine randomized controlled trials demonstrated that commercial hospital discharge packs negatively affect exclusive breastfeeding among women who had initiated breastfeeding before discharge. 8 In addition, the introduction of supplemental feedings has a detrimental effect on breastfeeding duration. 9
The impact of these messages on mothers and children is potentially far-reaching. One pediatrician anecdotally reported the results of asking 41 children 9–10 years old to draw everything necessary for a baby to grow up healthy. Ninety percent of these children drew a bottle. When queried, 68% said they believed that formula milk was the same as mother's milk. 10
Media messages about infant feeding and marketing of infant formula directly conflict with the breastfeeding recommendations of the AAP and do not follow the guidelines of the World Health Organization International Code of Marketing of Breast-Milk Substitutes. 11 The countermarketing promoted by this code aims to limit the marketing of infant formula and the use of competing imagery in the media and in health settings.
We sought to determine the message about bottle feeding versus breastfeeding conveyed to pregnant women and young children in graphic images on products marketed to these populations available for purchase in national chain stores. To our knowledge, no other study has addressed this question.
Materials and Methods
Items
We conducted an Internet search using the key words “baby shower” and “baby shower gift” to develop a list of products available for purchase for baby showers and expectant mothers. We chose these key words because we wanted to focus on readily available products marketed specifically for pregnant women in preparation for a birth. From among 25 items on our initial list, we selected those that would likely feature a graphic image. We added the category of baby dolls because they are often given as a gift to the infant or an older sibling.
Stores
To maximize generalizability, we chose national chain stores in the categories of mass retailer, department store, discount store, drug store, and/or gift shop. We restricted stores to locations within a 10-mile radius of Charlottesville (VA) City Center to expedite data collection and accessibility. For any chain with more than one eligible location, we chose one store using the simple randomization process of drawing from a hat. We decided that at least five of the 11 categories of items to be surveyed must be available for sale on the day the study was conducted for a store to be included.
Data collection
We visited stores on a weekend afternoon to replicate a realistic shopping trip for a baby shower or baby gift. Members of our research team, most of whom are medical students, visited each of the stores in groups of two and determined if the store sold at least five of the 11 categories of items. Next, we recorded each item within each of the categories, the name of the manufacturer, the presence or absence of graphic images, and the type of image. A graphic image was defined as any image other than a solid color, stripes, polka dots, or letters/words.
Data analysis
We entered all data into an Excel® (Microsoft) database. For each item category, we calculated the percentage featuring graphic images, the percentage featuring images of baby bottles, and the percentage featuring images of breastfeeding. (Note that we did not perform statistical tests as our numbers are total counts and not samples selected from a larger population.)
Results
We visited a total of 19 stores. We excluded one discount store that did not sell at least five of the 11 categories of items, leaving 18 stores that met our eligibility criteria (Table 1). We surveyed a total of 2,670 items in 11 categories (Table 2).
We found images of baby bottles in eight of the 11 categories. Thirty-five percent of baby dolls were packaged with a baby bottle. The percentage of items with baby bottle graphic images in the remaining categories was low, however. Roughly one in 10 greeting cards contained an image of a baby bottle. It is notable that we found no images of baby bottles in the categories of infant clothing, baby blankets, and disposable diapers (Table 3).
For baby dolls, we recorded whether or not the doll was sold with a baby bottle.
None of the 2,670 items surveyed contained a breastfeeding image (Table 3).
Discussion
Previous research has documented effects of social support, cultural norms, and media portrayal of bottle versus breastfeeding on infant feeding practices. Our study examined another potential source of influence: Baby shower and baby gift items. Based on what has been found in the media, we anticipated that images of bottles would be common and that images of breastfeeding would be rare or nonexistent. With the exception of baby dolls, baby bottles were much less common than we anticipated. However, as anticipated, images of breastfeeding were nonexistent.
The low prevalence of images of baby bottles on these products is encouraging. However, our results may underrepresent the true prevalence. Products containing the word “bottle” but no image of a bottle were not included because of our study protocol. It is worth noting that one set of bibs with images of baby bottles featured the text “Feed Me” on one and “Milk Junkie” on the other, reinforcing the message. Products sold at stores other than those surveyed might differ from those included in this study. In fact, the retailer we excluded for not selling products in at least five of our 11 categories sold only shower decorations containing images of baby bottles.
The finding of no breastfeeding images on these products is disturbing. Products with breastfeeding text but no image were excluded by our protocol. However, we did find one new baby greeting card that contained text about breastfeeding. Also of concern is the relatively large percentage of baby dolls sold with a baby bottle. Product designers may understandably shy away from images and products that might be perceived as offensive by some customers. The current controversy surrounding the breastfeeding doll “Breastmilk Baby,” manufactured by Berjuan Toys, suggests that the public is much less willing to accept pro-breastfeeding products for young children than they are to accept pro-bottle products. 12 Our finding of the relatively high proportion of baby dolls sold with a baby bottle supports this idea. Countermarketing efforts are needed to increase breastfeeding images and products for children to help make breastfeeding more socially acceptable and also help address and limit factors that are known to have a negative impact on breastfeeding. Research on the effects of dolls sold with or without bottles on young children's perceptions of breastfeeding is also needed.
Our study has several limitations. We do not have data to show the effects of viewing these images on feeding practices, and we did not find any studies in the literature assessing the impact of visual images on breastfeeding practices. Future studies could address this. Although we chose national chain stores for geographic generalizability, we conducted this study at one point in time and in one geographical area. Breastfeeding rates in Virginia are similar to national rates, and these results are likely generalizable across the United States; nevertheless, a comparison of different geographic regions or a study of changes in prevalence of images over time would be informative. 3 In addition, future studies could widen the scope of this study by including more retailers and more items that may be purchased around the time of the delivery of the baby, including products offered online.
Conclusions
One-fourth of mothers do not initiate breastfeeding, more than half do not breastfeed at 6 months, and 85% percent do not breastfeed exclusively at 6 months. Efforts are needed on all fronts to encourage breastfeeding initiation and duration and to discourage the use of supplemental feeding before 6 months, including advice given by physicians and others in medical settings, messages conveyed by media, and support given by family and friends. The presence of baby bottle images on baby shower and baby gift items undermines the idea that breastfeeding is the physiological norm, as does the absence of breastfeeding images on these products. We encourage product designers to explore ways to promote breastfeeding. We caution consumers to make informed choices in product selection. Lastly, we recommend that consumer advocacy and public health organizations call for the adoption of guidelines for these products similar to those of the World Health Organization International Code 11 to help mothers and families make appropriate and informed decisions about infant feeding.
Footnotes
Disclosure Statement
No competing financial interests exist.