Significance

What is already known about the topic? Breastfeeding-friendly policies can improve breastfeeding outcomes such as reducing disparities in initiation rates. There has been opposition to US policies that support breastfeeding, and little is known about the process for developing these policies.

What this study adds? This study suggests that those working to develop supportive breastfeeding policies may benefit from the following policy learnings—analyzing differences between proponents’ and opponents’ beliefs, framing advocacy messages beyond individuals and health, expanding the coalition outside of traditional health entities, and anticipating the opposition. This study also utilizes an established policy process framework.

Introduction

Breastfeeding benefits infants, mothers, families, communities, and society, and is an important foundation of population health (US Department of Health and Human Services 2011; American Public Health Association 2007; World Health Organization, UNICEF 2003). Unfortunately, some barriers may prevent even the most dedicated mother from breastfeeding. Policies that support breastfeeding can be part of the solution. For example, supportive maternity care policies and practices have a dramatic effect on breastfeeding success and can reduce disparities in breastfeeding initiation (Murray et al, 2007; DiGirolamo et al. 2008; California WIC Association and U.C. Davis Center for Human Lactation 2013), and worksite policies are associated with greater breastfeeding duration (Bai and Wunderlich 2013; Tsai 2013).

In the US, state laws that support breastfeeding across hospitals, worksites, and communities are associated with increased breastfeeding rates (Hawkins et al. 2013; Kogan et al. 2008). For instance, breastfeeding rates are higher when US states enforce worksite requirements for private areas to express breast milk and break time to breastfeed or pump (Smith-Gagen et al. 2014a, b). Less than half of US states have laws to support breastfeeding at work, and very few state laws address hospital maternity care practices that support breastfeeding or enforce mandates for breastfeeding policies (Murtagh and Moulton 2011).

Many US state health departments are committed to improving breastfeeding policies and practices as part of comprehensive approaches to improve maternal and infant health and reduce disparities in infant mortality (Jarris and Pliska 2012). However, there is opposition to US state breastfeeding legislation from hospitals, businesses, and groups that seek to minimize government regulation (Saadeh 2012). Public health practitioners need a better understanding of the policy development process so they can help design effective breastfeeding policy initiatives that incorporate factors associated with policy success (Pérez-Escamilla 2012).

In 2014, the Washington State legislature considered Breastfeeding-Friendly Washington (BFW) bills to create a voluntary recognition system for breastfeeding-friendly hospitals, clinics, worksites and child care settings. Senate Bill (SB) 6298 and House Bill (HB) 2329 were discussed in committees but were not passed. The purpose of this study was to understand the BFW policy process to inform future breastfeeding policy development.

Methods

We conducted a policy case study using semi-structured interviews and document analysis. We were guided by local advisors from state agencies and coalitions (e.g., state and local public health departments, state legislative staff, breastfeeding coalitions, hospital associations) and by the consolidated criteria for reporting qualitative research (COREQ) (Tong et al. 2007). This study was exempt by the University of Washington IRB (May 2014).

Framework

Policy process frameworks, such as the Advocacy Coalition Framework (ACF) (Sabatier 2007), provide a structure for understanding multiple influences on policy outcomes. We used the ACF to examine how groups of stakeholders were brought together by common values and beliefs to advocate for or oppose the BFW bills. The framework also identifies factors outside the immediate policy proposal and legislative process and highlights the importance of policy learning over time (Sabatier 1988). Further details about key ACF constructs of interest are provided in Table 1.

Table 1 Key components of the advocacy coalition framework (ACF)
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Participants

We recruited interviewees through purposive sampling (Miles et al. 2014). The criteria for participating in the study was for the participant to have knowledge of the process to develop and/or try to enact the breastfeeding-friendly Washington legislation; including people who proposed or opposed the legislation. We did not sample specifically for proponents and opponents as people do not always fall cleanly into these categories; e.g., may be supportive of the legislation when it is being written and then against it after discussing in committee. Advisors identified key players in the BFW policy process and sent them an introductory email to invite them to participate in the study. Interested parties completed a brief online survey with their contact information and best time to contact them, and research staff then contacted them via email and phone to review study protocol and schedule interviews. Participant recruitment continued until we reached our target goal of 40 interviewees.

Data Collection

The semi-structured interview guide asked about beliefs about breastfeeding practices and policies, roles in the BFW policy development and legislative session, past and current state policy efforts to support breastfeeding, and contextual factors. Trained interviewers (KF, LS, VB) conducted phone interviews from August 2014 to January 2015, obtaining verbal consent prior to each interview. Interviews lasted approximately 45 min, and participants were offered a $35 gift card for participation. Additional data were provided by documents such as emails, reports, legislative minutes, and the actual bills and amendments. These documents were obtained from interviewees at the end of the phone interview, when we asked them for documents that would help us to better understand how the BFW legislation was developed or put into place.

Data Analysis

Interviews were recorded and transcribed verbatim. Using a thematic analysis approach (Daly et al. 1997), members of the research team read and re-read (Rice and Ezzy 1999) interview transcripts to develop a list of deductive codes based on the ACF and inductive codes that emerged from the data. Team members (LS, EQ, VB, EP) coded transcripts independently, then met to review and compare codes, discussing discrepancies until consensus was reached. After coding, we (LS, EQ, VB, DJ) summarized coded text by each ACF construct. This process highlighted key themes and subthemes while also providing a framework for interpreting the findings (Miles et al. 2014). Atlas.ti (Atlas.ti 7.5.7, GmbH, Berlin) was used to support analysis.

We (VB, DJ) reviewed, coded and summarized documents. Documents provided supplementary information unavailable from the interviews and were used for triangulation (Bowen 2009). We also presented findings to advisory group members whose feedback was incorporated in this report.

Results

Twenty of 45 identified state-level policy actors and 21 of 65 identified breastfeeding coalition members participated in the interviews (N = 29). We excluded twelve coalition interviews that did not describe state policy processes. Interviewees were from the State House and Senate; the state health and early learning departments, hospital association, and employees union; and health advocacy and breastfeeding coalitions. The majority were proponents of the Breastfeeding-Friendly Washington (BFW) bills despite several attempts to recruit bill opponents. Interviewee characteristics are summarized in Table 2.

Table 2 Participant characteristics (N = 29), Breastfeeding-friendly Washington (BFW) bills case study, 2014–2015
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We analyzed 54 documents to supplement interview findings. Documents provided further information on bill opponents’ perspectives and strategies, and on specific legislative session activities that were not recalled by interviewees. Unless otherwise noted, results of the document analysis did not contrast with interview findings.

We used the ACF to describe the policy development process of the BFW bills (Fig. 1). Illustrative quotes are provided in Table 3.

Fig. 1
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Adapted from Breton et al. (2006)

A modified advocacy coalition framework for statewide breastfeeding legislation

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Table 3 Themes, subthemes and sample quotes from the Breastfeeding-Friendly Washington (BFW) bills case study, 2014–2015
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BFW Policy Subsystem

Coalitions are made up of various policy actors who share beliefs and coordinate activities over time. For the BFW bills, two coalitions comprised the policy subsystem—proponents and opponents. Proponents included several state legislators, the state health department and hospital association, breastfeeding advocacy coalitions, and the governor’s office. The main opponents were corporations that manufacture infant formula. Document analysis confirmed these corporations were represented by an advocacy organization that was sponsored by an international association of formula manufacturers and marketers. Historically, both proponents and opponents have publically shown support for breastfeeding. Despite this general support, proponents and opponents diverge on how to overcome the continued environmental challenges to breastfeeding (e.g., lack of adequate time and space to pump at work; free formula provided universally at many hospital settings).

The Origins of the BFW Bills

The behavior of coalition members is influenced by contextual factors that are relatively stable parameters and often resistant to change (i.e., societal values or finite resources) and by more dynamic external events that can radically alter a policy subsystem (e.g., a change in government or socioeconomic conditions).

Relatively stable parameters: Interviewees described a number of US-specific factors that pose environmental challenges to breastfeeding: “Mixed messages” about breasts as sexual objects and as a source of nourishment for babies; a history of limited policy support for women and families; and, a capitalist economy that may not prioritize public health. Interviewees saw improved breastfeeding policies as a way to promote population health, economic benefits for workplaces, and safe and fair labor conditions for mothers.

External events: Participants mentioned many external events that set the stage for developing the BFW bills. In particular, social and behavioral norms have changed considerably: more women with children under one are working, more women are articulating a desire to breastfeed and the need for supportive environments, and “more elected officials who are women and/or have young children.” Younger generations also seem more comfortable breastfeeding. There has been increasing evidence about breastfeeding benefits for not only babies and mothers but also for families, workplaces, and the public’s health. Table 4 provides recent breastfeeding recommendations, policies and grants that buoyed the BFW policy development.

Table 4 International, national and local recommendations, policies, and grants identified by interviewees as setting the stage for the Breastfeeding-Friendly Washington bills, 2001–2014
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Coalition Beliefs

The ACF suggests people engage in policymaking to translate their beliefs into action. The framework describes three types of beliefs that guide coalitions– deep core (fundamental and unlikely to change), policy core (more specific but still unlikely to change), and secondary aspects (related to policy implementation and most amenable to change). Exemplar quotes for each of these types of beliefs is provided in Table 3.

Proponents of the BFW bills believed it is in society’s best interest to promote health (deep core). As one participant shared, “we’re trying to make the next generation healthier for kids, and we should make sure we give kids the best start.” Proponents’ policy core beliefs included: viewing breastfeeding as the healthiest option, that every woman has a right to choose to breastfeed, and that breastfeeding is a private decision that takes place in a public context (given the environmental constraints to exclusive breastfeeding and pumping). Many proponents had a positive personal experience with breastfeeding and had overcome challenges to breastfeed. They believed a voluntary recognition program was an appropriate approach (secondary aspect) for the state given limited state resources and the expected pushback from a mandatory program.

Interviewees provided their perspectives on opponents’ beliefs. They thought that opponents held the deep core belief that society should not infringe on the rights and freedoms of individuals and institutions; as such, opponents’ policy core beliefs were that the BFW bills would constrain women and environments, that breastfeeding is a private matter, and that the state policy would be “essentially promoting a kind of pressure” on women to choose to breastfeed. Interviewees felt that many opponents had experienced negative personal experiences with breastfeeding in which they or someone they knew felt guilty for not breastfeeding. Interviewees believed that opponents saw the BFW bills as government overreach and as mandates (secondary aspects) to breastfeed even though the bills supported only a voluntary recognition program.

Coalition Resources and Constraints

Proponents of the BFW bills had several resources to support policy development. They had champions in state agencies, in both parties and branches of the legislature, and in advocacy and other community-based organizations. They could cite increasing evidence about breastfeeding’s benefits, and the BFW bills aligned well with their organizational missions. Proponents were hindered by limited funding to promote the bills, the narrow membership of their coalition (which included primarily health-related entities), and some members’ viewing breastfeeding as important but not “critical.”

Interviewees thought opponents benefited from having ample funding (as formula companies and other lobbyists) to challenge the bills. Not passing the bills also aligned with economic interests to maintain or expand formula’s reach to new families. Opponents may have been constrained by having to operate in the free market and the need to appear to support breastfeeding as a public health issue, even if it interferes with their bottom line. Sample quotes about this and other ACF constructs are offered in Table 3.

Coalition Strategies

Proponents’ key messages to legislators centered on increasing evidence to support why breastfeeding is good for mothers, babies, worksites, and society. Sharing information about these health and other benefits was how proponents aimed to gain support for the bills; no formal strategy was in place to combat the opposition that emerged later in the legislative session.

Meanwhile, proponents felt that the opposition waited until the end of the session to spread messages about how the BFW bills would limit choices for women and families. Women testified that the BFW bills would make them feel guilty or coerced to breastfeed; opponents generally framed the bill as “the government telling people what to do.” Proponents believed the opposition distorted the intention of the bills, saying that families would be forced to breastfeed and could not choose formula if they wanted or needed it. Document review showed that opponents described the BFW bills as limiting formula to everyone, while the bill language only limited health care providers from marketing formula through gift bags, coupons, and free samples.

Constraints and Resources of the Legislative Session

The ACF suggests that policymaking takes place in a broader system that sets the boundaries for action and provides each coalition with different constraints and opportunities.

The legislative session was constrained by several factors, particularly a short session (2 months) and a climate of limited resources and competing state priorities (even among proponents), such as education and corrections. Even though breastfeeding support was seen as an important issue, it was not a top priority amidst other issues the legislature had to address. Furthermore, there was limited awareness about what specific, evidence-based policies were needed to optimally facilitate breastfeeding. The bill was also perceived as Democrat-led and sanctioned by the Governor, which meant some legislators who were supportive of breastfeeding did not support bills that would give the other party a win. No specific resources of the legislative session were identified by either coalition.

Policy Decisions and Outcomes

In order to address the opposition, amendments were passed to remove bill restrictions on pacifiers and formula marketing and to limit the House Bill to hospitals only. The BFW bills had some traction in both committees, but never received formal votes on the floor. Many proponents were comfortable with this outcome since the original bills had been “watered down until they lost most of their meaning.” Proponents also understood that bills are not often passed on their first try. Recognizing that a bill was not the only way to enact policy, the state department of health has since launched a voluntary recognition program for hospitals that includes many elements from the BFW bills (Washington Department of Health 2015).

Conclusions for Practice

The 2014 Breastfeeding-Friendly Washington (BFW) bills provided an opportunity to test coalitions, develop legislation based on evidence-based policies and practices, design messages to support policy adoption, and hear concerns from various stakeholders. This policy case study helped identify key factors in policymaking, including stable and dynamic contextual factors; beliefs, resources, and strategies of each coalition; constraints of the legislative session; and subsequent policy decisions and outcomes. Other public health policymaking efforts may benefit from these important policy learnings.

Analyze beliefs: There were several dichotomies between proponents’ and opponents’ attitudes, from deep core beliefs about public health versus free markets; to policy core beliefs that viewed breastfeeding as a public vs. private matter, breastmilk as the healthiest option versus one option for feeding babies, and breastfeeding policies as supporting women’s right to choose versus constraining women’s right to choose not to breastfeed. These contrasting beliefs inspired very different policy approaches (secondary aspects): proponents supported a voluntary recognition program that would change environments to make it easier to choose breastfeeding, while opponents viewed the BFW bills as government overreach and mandates that infringed on individuals’ right to choose formula and on organizations’ right to run their businesses. The personal also proved to be political: personal experience influenced support or opposition to the bills depending on positive or negative experiences with breastfeeding.

Frame beyond individuals and health: Proponents’ policy core beliefs and messaging centered on the health of mothers and babies. The Berkeley Media Studies Group (BMSG 2010) has found that a health argument for breastfeeding is insufficient since it oversimplifies breastfeeding as a function of an individual mothers’ intent; not as an outcome of a society that does not support women, children and families. Focusing on health benefits absent of environmental barriers is akin to encouraging children to play outside without regard to neighborhood safety. Using a fact-based argument (e.g., research evidence about breastfeeding benefits for moms and babies) to support breastfeeding is also futile when up against deep core and policy core beliefs surrounding privacy and capitalism. Expanding the frame beyond individuals and health is needed so that non-health policy actors have a stake in passing bills to support breastfeeding.

Broaden the coalition: Likewise, while there was general support for breastfeeding within and across coalitions, a broader coalition of proponents is needed beyond traditional health entities. The BFW bills were perceived as an extension of the state public health agency instead of a comprehensive movement. Broadening the coalition to strategically and specifically engage women, families, providers, and organizations across sectors may better support policy change and anticipate and address opponents’ concerns. It is particularly important to engage labor and other business groups, professional associations for nurses and pediatricians, and nursing mothers.

Anticipate the opposition: The general support for breastfeeding across policy actors, along with the late-breaking opposition, led to the misperception that the BFW bills would pass easily. Previous breastfeeding policy opponents (businesses) were largely absent from the debate, and formula companies had not opposed earlier breastfeeding policy efforts since they did not infringe on their bottom line. The ACF suggests that brokering between coalitions is needed early in the policy process so that proponents can proactively address opponents’ concerns instead of being caught on the defensive. The recently approved Hospital Infant Feeding Bills in California (SB 402 and SB 502) (California WIC Association 2014) suggest that legislation to promote evidence-based policies can pass when explicit language against formula feeding is removed from the bills.

This study was limited by several factors. First, we were unable to obtain interview data from opponents of the BFW bills despite several attempts to both find and invite them to participate. Their lack of interest in participating in the study is not surprising given that they were not supportive of this state legislation. As such, all interviewees were proponents or were more neutral about the bill either during its development or process of trying to get passed. To address this limitation, we reviewed documents to locate accurate bill details and confirm interview findings, especially in reference to the opposition. Our sample also lacked racial/ethnic diversity. We recognize that this is a limitation of the breastfeeding promotion field that has traditionally been led by White women.

Reflexivity is the ‘active acknowledgement by the researcher that her/his own actions and decisions will inevitably impact upon the meaning and context of the experience under investigation’ (Horsburgh 2003: 309); the positioning of research team members in relation to the group of study is one way to understand reflexivity in context. Our study team members included people with different positions from insider to outsider of the BFW legislation—people who were unfamiliar with the BFW legislation, people who knew about the legislation but were not involved in its development or attempt to enact or oppose the bills, and people who were familiar with the BFW legislation through previous research on evidence-based breastfeeding policies. Our advisors further provided context for the BFW legislation development and attempt to pass the bills. Including these different positions helped strengthen our research by sensitizing the researchers to threats to trustworthiness, and to raising awareness of potential biases and increasing diligence during the data analysis process (Berger 2013). We also used triangulation by comparing analysis of the same content by two members of our research team to help ensure that the data analysis was an accurate representation of the themes.

Public health practitioners are charged with developing policies as one of their ten core competencies as policies that create healthier environmental contexts have an enormous potential to promote population health across communities (Frieden 2010). Theories such as the ACF can help distill key factors that drive policy change in a complex policymaking environment (Breton and De Leeuw 2011). Other public health studies utilizing the ACF report similar findings as in this case study; such as the importance of having a broad coalition and identifying the beliefs and external factors that shape the policy-making environment (Breton et al. 2006; Johnson et al. 2012; Ulmer et al. 2012). While this study was conducted on a US state policy legislation to support breastfeeding, we see broader implications for other countries who have a social responsibility to create enabling environments for women who want to breastfeed (Rollins 2016). This study can inform the efforts of practitioners and policymakers who are working to improve breastfeeding outcomes through policy change.