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55 HEALTH ECONOMICS: MAKING COMMUNICATIONS ON MATERNAL NUTRITION WORK
Health Economics:
Making communications on
maternal nutrition work
Thomas Breisach ioral and dietary rules. The arguments in favor of breastfeeding,
FOM University of Applied Sciences, however, were based not on scientific, medical or nutritional
Munich, Germany findings but rather on popular psychological rationales or the
supposed laws of nature.
st
In our own 21 century, the debate on maternal nutrition
and breastfeeding is still very much alive, but, sadly, “despite
Key messages impressive scientific advances and massive economic growth …
the hope of achieving significantly improved health for a greater
> For millennia, the best approach to maternal nutrition proportion of the world’s people … has become an even more
3
and breastfeeding has been the subject of debate – usually distant prospect.”
without involving directly affected mothers. Maternal nutritional status during and after pregnancy has
a crucial influence on fetal growth and early child development
> The economic growth potential of maternal nutrition and later exposure to the risk of contracting a wide variety of
should be given greater emphasis in communications communicable and non-communicable diseases. Pregnant and
on the topic. breastfeeding women are in a particular phase of life and have
very special dietary needs.
> Learning from the health communication activities
of the past shows that nutrition communication can only “ The hope of achieving significantly
be successful if it is dialogue-oriented and if the relevant improved health for a greater
target groups are involved.
proportion of the world’s people
The ancient debate on maternal nutrition has become an even more
As long ago as the days of Ancient Greece and Rome, maternal distant prospect
nutrition and breastfeeding were the subject of controversial ”
public debate. However, these topics were mainly discussed by
wealthy and well-educated men such as Pseudo-Plutarch or Tac- Achieving goals in the fields of adherence and prevention
itus, without involving directly affected mothers at all. is very often dependent on behavior change on the part of the
Even 2,000 years ago, social and regional contexts played target groups. Experience to date indicates that recommenda-
a crucial role in differentiating approaches to early childhood tions for healthy nutrition or dietary supplementation are often
1 Historic sources state, for instance, that poorly implemented during and after pregnancy, either because
nutrition and care.
malnutrition due to overly short or otherwise inadequate breast- pregnant or breastfeeding mothers have their own ideas about
2
feeding results in bladder stones and anemia. appropriate nutrition and dietary supplementation or else be-
Historic sources that discuss breast-milk substitutes – for cause they lack the prerequisite knowledge. The sources of ad-
instance, honey potions or diluted wine – indicate that the use vice most trusted today in matters of diet are general medical
of animal milk and milk substitutes was not common compared practitioners and the Internet. It is well known that effective
with breastfeeding and wet nursing. To avoid putting very young health communication and education are very powerful tools
babies at risk, wet nurses were the subject of stringent behav- 4 However, this is
for behavior change in matters of nutrition.
SIGHT AND LIFE | VOL. 30(2) | 2016 HEALTH ECONOMICS: MAKING COMMUNICATIONS ON MATERNAL NUTRITION WORK 56
A baby at the breast. The best approach to maternal nutrition and breastfeeding has been the subject of debate for millennia.
57 HEALTH ECONOMICS: MAKING COMMUNICATIONS ON MATERNAL NUTRITION WORK
only the case if the traditional communication is replaced by Just over a decade ago, Szwajcer analyzed the nutrition-
a more dialogue-based approach that is tailored to the specific related information-seeking behaviors and motives of young
target group.5 Dutch women before and during pregnancy. The main informa-
tion sources of the test group were the Internet and their own so-
Maternal nutrition as a global communication challenge cial environment. Pregnancy-specific nutrition information was
From a health economics point of view, improving maternal nutri- important to the test group because such information helps pro-
tion can succeed only if “countries have considerable self-inter- tect the health of the fetus.11 In Asia (e.g. Bangladesh), lack of
6
est in improving the health of their own … population.” However, (health) education, client orientation and direct communication
12
the motivation behind these efforts is not purely philanthropic. on the part of health personnel leads to a lack of knowledge
Political and economic leaders have learned in recent years that about ante- and postnatal care and maternal nutrition, and the
13
many countries will not be able to climb out of poverty as long as services offered are therefore not well accepted. For efficient
a major part of their population is unable to achieve the nutrition- and effective nutrition programming, communication is key.
al status necessary for a healthy and productive life. For this rea-
son, the effective communication of general nutrition concepts is Good health communication offers economic
of extreme relevance to the economics of healthcare. Undernu- and personal benefits
trition reduces economic growth by at least 8%. The quality of Since the 1980s, most health communication activities have
nutrition a child receives while in the womb and during its infan- focused primarily on behavior change methodologies as pro-
7
cy has irreversible effects on its future health and development. moted in expert circles and leading media. The protagonists
have overestimated the effectiveness of these activities, be-
“ The quality of nutrition a child cause they have focused too heavily on telling people what to
receives while in the womb and do in a very sophisticated manner rather than listening to and
involving the target groups themselves. Apart from a frequent
during its infancy has irreversible disregard for the sociocultural attributes and educational back-
effects on its future health ground of the target groups, one chief error has been the lack
of interest shown in the information tools normally used by, for
and development example, malnourished women. Furthermore, health communi-
” cation has mainly been seen as a one-way street. In the USA
and Japan, for example, education, household income and other
Despite the importance of the link between early nutritional social determinants are the main drivers of different approach-
input and subsequent growth and development, the history of es to accessing health information, as well as of disparities in
14
the Western world shows that this issue has not been at the top health status. However, compared with health information
of the agenda of the world’s political leaders – or, indeed, of the supplied by healthcare providers and the Internet, levels of
majority of pregnant and (breastfeeding) mothers, either. trust in health information provided by the mass media are not
15
Public health has always been influenced by medical and linked to socioeconomic status. Empowering the poorest by
scientific arguments as well as by ethical and political consid- informing them about health benefits should therefore involve
8 th
erations. In the Great Britain of the 19 century, for example, two-way communication.
the majority of today’s elemental rules of infant care simply did Today, a variety of much more target-group-oriented commu-
not exist. Many poor people did not make use of midwives for nication approaches have been developed and put into practice.
the delivery of babies, and if the mother died in childbirth, the According to Servaesa and Malikhaob, successful health com-
9
baby was allowed to die as well. “Thousands of babies were munication should consist of behavior change communication,
born annually to mothers who were underweight and under- mass communication, advocacy communication, participatory
nourished, who had contracted pelvises, who worked too hard … communication, and structural and sustainable social change
16
during the pregnancy, and who received no sound advice, either communication. To be successful, behavior change communi-
from health societies, or from any supporting network of wom- cation has to be interpersonal. Mass communication should fo-
10
en, about pre- and antenatal care.” The question is therefore cus on special community media and platforms and mass media.
whether health communication about maternal nutrition seen Advocacy communication has to consist of both interpersonal
from an economic perspective should simply focus on the pre- communication and mass communication, while participatory
vention of deficiencies or should rather highlight the positive communication should be based on interpersonal communica-
biological effects of maternal nutrition on (lifetime) health. The tion and communities. Structural and sustainable social change
answer is obvious: both. communication should be an amalgam of interpersonal, partici-
SIGHT AND LIFE | VOL. 30(2) | 2016 HEALTH ECONOMICS: MAKING COMMUNICATIONS ON MATERNAL NUTRITION WORK 58
patory and mass communication. However, what mothers gener- 05. Servaesa J, Malikhaob P. Advocacy strategies for health
17
ally want from health care professionals is advice. communication. Public Relat Rev 2010; 36:42–49.
06. Friedman E, Gostin L. Pillars for Progress on the Right to Health:
“ What mothers generally want Harnessing the Potential of Human Rights through a Framework
from health care professionals Convention on Global Health. In: Grodin M, Tarantola D, Annas G
et al (eds). Health and Human Rights in a Changing World.
is advice New York: Routledge, 2013: 246.
” 07. Black, R, Alderman H, Bhutta Z et al. Maternal and child nutrition:
building momentum for impact. The Lancet, Vol 382, 2013: 372ff;
Every patient-centered communication initiative has to be Koletzko B, Dodds P, Akerblom H et al. Early Nutrition and its later
adapted to the specific situation and needs of the individual tar- Consequences: New Opportunities. Springer Dordrecht, Berlin,
get group. Key to the success of all public health communication Heidelberg, New York 2005: Preface.
activities is a strategy-based approach – and this is the reason 08. Beck A. Issues in the Anti-Vaccination Movement in England.
why so many health communication initiatives fail. Medical History 4; 1960:310319.
09. Gilbert B. The Evolution of National Insurance in Great Britain:
Conclusion The origins of the welfare state, London: Michael Joseph, 1966:90.
Today, the role of media- and dialogue-oriented communication 10. Wohl A. Endangered lives: public health in Victorian Britain.
in influencing health is well acknowledged. The main issue to Cambridge, Mass: Harvard University Press, 1983:12
be addressed is the communication focus in the context of ma- 11. Szwajcer E, Hiddink1 G, Koelen M et al. Nutrition-related
ternal nutrition. Maternal nutrition communication should not information-seeking behaviors before and throughout the course
be one-dimensional. To achieve a change of mindset, it has to of pregnancy: consequences for nutrition communication.
address both the affected individual and the more general eco- Eur J Clin Nutr 2005;59(1):57.
nomic potential of good maternal nutrition. 12. Rahman P, Matsui N, Ikemoto Y. The chronically poor in rural
To achieve a broader social acceptance of maternal nutrition Bangladesh – Livelihood constraints and capabilities. New York:
campaigns and activities, health workers should therefore re- Routledge, 2009:68.
consider their approach and try to base their communication ac- 13. Anwar I, Ki llewo J, Chowdhury M et al. Bangladesh: Inequalities
tivities on two different aspects: a) the individual and economic in Utilization of Maternal Health Care Services – Evidence from
outcome of efficient maternal nutrition; and b) a less dogmatic Matlab. Reaching the Poor Paper No. 2, Washington 2005:132.
approach to their style of communication. The critical success 14. Ishikawa Y. Socioeconomic Status and Health Communication
factor is, however, target group orientation. Inequalities in Japan: A Nationwide Cross-Sectional Survey. PLOS
ONE 2012, vol. 7, issue 7:1.; Viswanath K, Ackerson L. Race, Ethnicity,
Correspondence: Thomas Breisach, Language, Social Class, and Health Communication Inequalities:
FOM University of Applied Sciences, Study Center Munich, A Nationally-Representative Cross-Sectional Study. PLOS ONE 2011,
Arnulfstr. 30, 80335 Munich, Germany Volume 6, Issue 1:1, 7.
Email: thomas.breisach@fom.de 15. Ishikawa Y. Socioeconomic Status and Health Communication
Inequalities in Japan: A Nationwide Cross-Sectional Survey.
PLOS ONE 2012, vol. 7, issue 7:1.
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02. Ibid pp 514–515.
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New York: Oxford University, 2013.
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