Loss aversion and the limits of breastfeeding promotion: a behavioral policy perspective

Abstract

Background

Breastfeeding confers substantial health benefits for infants and mothers, yet global exclusive breastfeeding rates remain far below recommended levels. Although extensive epidemiologic evidence documents the risks associated with formula feeding, breastfeeding promotion remains an outlier within public health communication: unlike campaigns addressing smoking, vaccination, or screening, it relies predominantly on gain-framed messages emphasizing benefits rather than on transparent discussion of risks. This Debate examines how behavioral science, especially research on loss aversion and message framing, can inform breastfeeding promotion, and why risk-based communication has been uniquely constrained in this domain.

Main text: risk communication, guilt, and commercial influence

Concerns about inducing maternal guilt have shaped breastfeeding promotion for more than two decades, contributing to unusually cautious, euphemistic public messaging that downplays the risks associated with formula feeding. Qualitative research shows that mothers often experience guilt not from accurate risk information but from the moralization of infant feeding and from structural barriers such as inadequate paid leave, limited lactation support, and lack of access to safe donor milk that make exclusive breastfeeding difficult to achieve. Behavioral science further suggests that parents may be especially sensitive to loss-framed information because feeding decisions affect the infant rather than the self, and that cultural context shapes how framing works. At the same time, commercial formula marketing strategically leverages maternal emotion, reframes breastfeeding advocacy as divisive or judgmental, and promotes formula as a “guilt-free” alternative. This dynamic has contributed to a policy environment in which transparent risk communication is often perceived as harmful when formula marketing exerts profound and targeted influence on parental decision-making.

Conclusion

Silencing risk communication because of fear of maternal guilt is neither evidence-based nor ethically justified. Breastfeeding promotion at the population level must be able to communicate risks transparently (including loss-framed information where appropriate and evidence-based) while pairing this with strong structural supports, protection from commercial influence, rigorous message testing, and compassionate, individualized clinical care. Advancing an evidence-based, emotionally intelligent, and context-sensitive approach to risk communication is essential for ensuring that breastfeeding promotion is both effective and equitable.

Clinical trial number

Not applicable.

Background

Breastfeeding promotion holds immense potential for public health, but it faces persistent social, economic, and political challenges. The most recent estimates suggest that global near-universal exclusive breastfeeding for the first six months of an infant’s life could prevent close to 800,000 child deaths and 20,000 maternal deaths annually. These benefits extend beyond infant survival: breastfeeding reduces the risk of breast and ovarian cancer for mothers and supports optimal child development [1]. For low and middle-income countries, a systematic review found that, compared to exclusively breastfed infants under five months of age, the risk of all-cause mortality was 48% higher among predominantly breastfed infants, 184% higher among partially breastfed infants, and 1,340% higher among non-breastfed infants compared with exclusively breastfed infants [2]. More recent evidence from a meta-analysis for low- and middle-income countries (LMICs) reports an increased risk of neonatal mortality and a higher risk of necrotizing enterocolitis (NEC) despite greater weight gain in low birthweight and premature infants with formula feeding [3]. For high-income countries, evidence from systematic reviews and primary studies shows a risk reduction with more breastfeeding and no clear threshold of breastfeeding duration that appeared to be most beneficial for any outcome, for the following conditions: respiratory and gastrointestinal infections, otitis media, allergic rhinitis, asthma, malocclusion, inflammatory bowel disease, type 1 diabetes, rapid weight gain and growth, obesity, high systolic blood pressure, childhood leukemia, and infant mortality [4]. Although consistent associations have been established, significant gaps remain in accurately quantifying the risks associated with formula feeding across different practices and populations, partly due to insufficient research funding in this area [1, 5]. Yet, fewer than half (44%) of all infants worldwide are exclusively breastfed for the first six months [6], with substantial regional variation reported as 34.5% for the Eastern Mediterranean and 55.2% for Southeast Asia/Western Pacific [7].

Why framing matters for breastfeeding promotion

I suggest that behavioral science, particularly message framing, offers a promising and under-tested strategy for improving breastfeeding outcomes. Framing leverages cognitive biases such as loss aversion, where individuals are more sensitive to potential losses than equivalent gains [8]. In health promotion, this often translates into messaging like “smoking kills” rather than “nonsmokers live longer” [9]. Recent meta-analytic evidence indicates that while overall framing effects in health promotion are modest and highly context-dependent, loss-framed messages tend to be more persuasive in collectivist and survival-focused cultures. In contrast, gain-framed messages resonate more in individualistic and expression-oriented settings [10]. This viewpoint does not present new empirical data and relies on a synthesis of existing behavioral, qualitative, and policy literature; as such, its conclusions are intended to inform future research and policy development rather than to offer definitive causal claims about message effectiveness.

What we don’t know about current campaigns

While no high-quality, large-scale content analyses of breastfeeding promotion campaigns appear to exist, anecdotal evidence from a small U.S.-based qualitative study suggests that public health messages overwhelmingly emphasize the benefits of breastfeeding, while rarely referencing the risks associated with formula feeding [11].

I propose that the reasons for the apparent cultural and political reluctance to use loss framing in this uniquely relational health decision stem from two intersecting forces: commercial interference [5] and a specific discomfort with maternal guilt, which is rarely encountered in other areas of public health messaging [12]. Knaak [13] links this discomfort to the moralisation of risk and the construction of “good mothering,” which makes any invocation of risk or responsibility in infant feeding easily read as moral blame. As Taylor and Wallace [12] note, breastfeeding advocates acknowledge pressure to avoid language that could be construed as guilt-inducing, leading to unusually cautious and euphemistic communication of formula-feeding risks. At the same time, the formula industry aggressively promotes its products through emotionally targeted and algorithmically amplified messaging [14, 15]. Strategic campaigns have reframed breastfeeding from a public health imperative into a matter of private lifestyle choice, weakening calls for systemic lactation support and positioning formula as the socially acceptable default [5, 16]. This double standard creates an environment where evidence-based breastfeeding advocacy is portrayed as moralizing or harmful, while commercial influence is rarely questioned by parents, caregivers, and many frontline health professionals, despite extensive critiques in the academic and public health literature [5]. I argue that this silencing, rooted in fear of inducing maternal guilt, has distorted public health communication, undermined informed decision-making, and limited the integration of effective behavioral strategies into breastfeeding promotion.

Framing, loss aversion, and the silence around risk

Loss aversion in public health communication

People tend to react more strongly to potential losses than to equivalent gains, a well-established psychological tendency known as loss aversion [8]. In public health communication, this insight is operationalized through message framing, which is the strategic choice to emphasize either the benefits of a health behavior (gain framing) or the risks of not engaging in it (loss framing). Framing leverages loss aversion by making health risks more vivid and emotionally salient, a strategy widely employed in campaigns addressing high-stakes behaviors, such as smoking cessation or vaccination uptake [9].

While robust evidence confirms loss aversion in financial decision-making [17], the situation for health behaviors is more nuanced. Recent meta-analytic findings suggest that framing effects in health promotion are generally small and highly context-dependent, varying by cultural background, behavioral function (prevention vs. detection), and perceived risk. Specifically, loss-framed messages appear slightly more persuasive for health detection behaviors such as cancer screening, while gain-framed messages show a modest advantage in promoting health-enhancing behaviors like exercise and dietary improvements. However, these differences are modest, and the overall impact of framing remains limited [10]. The implications for breastfeeding, a complex preventive behavior that is dyadic, embodied, and deeply shaped by social context, remain unclear.

Cultural contexts and message effectiveness

Cultural context further shapes the effectiveness of health message framing. Loss-framed messages tend to be more persuasive in collectivist and survival-focused cultural settings, whereas gain-framed messages resonate more in individualistic, expression-oriented contexts [10]. These insights underscore the importance of tailoring health communication strategies to target populations’ cultural norms and values.

Breastfeeding as the exception

Despite this meta-analytic evidence, risk-framed messaging continues to be used in many public health campaigns addressing risky or harmful behaviors, for instance, “smoking kills” or “unprotected sex spreads HIV,” where the potential losses are made explicit to prompt behavior change [10]. Breastfeeding promotion, however, stands out as an exception. In high-risk contexts, including LMICs where exclusive or partial formula feeding is associated with substantially elevated infant mortality risks [2], public health messaging predominantly uses gain-framed language such as “breastfeeding protects” rather than “formula feeding increases the risk of mortality” [2].

Qualitative findings from a small U.S. study suggest that breastfeeding promotion messages generally highlight benefits rather than risks [11]. Table 1 shows that risk-framed messaging has occasionally appeared in advocacy contexts, particularly in some LMIC public health campaigns and NGO materials. However, these instances are rare and have not shaped the dominant discourse. They stand out precisely because they deviate from the norm. The observation that posters stating “formula feeding increases risk of disease” are so uncommon and often provoke discomfort or backlash underscores just how entrenched the avoidance of loss-based framing has become. Table 1 summarizes campaign language to illustrate the contrast between gain- and risk-framed messages in breastfeeding promotion.

Table 1.

Gain and loss framing in breastfeeding promotion

	Gain framing	Loss framing	Comments
Infant Health	“Breast milk is best for your baby. Breast milk lowers baby’s risk of ear infections. Breast milk lowers baby’s risk of diarrhea. Breast milk lowers baby’s risk of pneumonia.” [18] “Breastfeeding protects your baby from diarrhea, chest and ear infections.” [19]	“The Risks of Formula Feeding: Children who are fed with formula milk are at higher risk of having lung infections, ear infections, infection from contaminated formula milk, chronic diseases, lower intelligence, allergies, asthma, heart disease, obesity, childhood cancers, diarrhea, diabetes.” [20]	Gain-framed messaging highlights benefits, while risk-framed messaging emphasizes risks of not breastfeeding. Loss framing may elicit stronger emotional responses.
Maternal Health	“Breastfeeding has health benefits for the mother, too! Breastfeeding can help lower a mother’s risk of high blood pressure, type 2 diabetes, and ovarian and breast cancer.” [21]	“Mothers who do not breastfeed: - May become pregnant sooner - Have increased risk of anemia, ovarian cancer, endometrial cancer, and breast cancer” [20]
Society: climate effects	„Prioritising and supporting breastfeeding will reduce the growing climate impact of artificial infant feed supply chains.“ [22]	“Formula milk contributes to environmental degradation and climate change” [23]	Loss framing may appeal more in collective-focused cultures.
Society: health care costs	“Investing in breastfeeding means investing in the future. It supports healthier populations, reduced healthcare costs, and stronger economies.” [22]	“Failing to breastfeed costs the global economy around US$302 billion every year” [24]	Loss framing is common in cost-related advocacy. It targets policymakers and funders by highlighting the economic burden of formula feeding.

Notes: While some meta-analyses such as Yeung et al. [10] distinguish between general positive/negative framing and more narrowly defined gain/loss framing, this article focuses specifically on the latter, rooted in the Prospect Theory-derived concept of loss aversion

Across domains, gain-framed messaging is more prevalent in public-facing breastfeeding campaigns, often due to perceived concerns about maternal guilt. Messaging strategy should therefore be aligned with both the target audience (e.g., public vs. policymakers) and behavioral goal. Loss framing should be shame-free and focus on concrete, actionable risks; evaluation should be preregistered and paired with enabling support.

The mother–baby dyad and the moral politics of guilt

Risk aversion when deciding for others

Breastfeeding is unique among health behaviors in that it involves a dyadic decision that intimately connects the health trajectories of two individuals. This dynamic is rooted in mammalian neurobiology: extensive research shows that hormonal and neural mechanisms (particularly involving oxytocin, dopamine, and the medial preoptic area) reorient maternal motivation to prioritize the infant’s well-being over the mother’s own immediate concerns [25]. In behavioral research, decision-making becomes more risk-averse when individuals act on behalf of others, particularly when health is at stake [26, 27]. Parents making feeding decisions are therefore likely to experience heightened moral responsibility, especially when faced with messaging that emphasizes the risks of not breastfeeding.

Importantly, breastfeeding is not a one-time decision but an ongoing behavioral commitment, often repeated many times daily over months or years [1]. This makes it more akin to long-term health behaviors such as nutrition, sleep, or physical activity, rather than discrete choices such as vaccinations or cancer screenings. As such, breastfeeding requires sustained physical, emotional, and logistical effort and support [28]. Recognizing this effort does not preclude communicating the risks of formula feeding. On the contrary, it underscores the importance of equipping families with complete, evidence-based information to make fully informed decisions.

Structural gaps and the origins of guilt

Given the neurobiological mechanisms discussed above, risk-framed breastfeeding messages may resonate more strongly with mothers because they are evolutionarily primed to avoid harm to their child. However, this same dynamic can become disempowering when mothers are expected to carry all the responsibility while lacking systemic support. In many health systems, there is no paid maternity leave, no skilled lactation care as the default [29], and no access to safe donor milk [30, 31], which might enable exclusive breastfeeding in cases of delayed lactogenesis II or other early breastfeeding challenges and should therefore be considered part of lactation support infrastructure. Risk communication can then become counterproductive: mothers are told what the safer feeding choice is, but not given the means to achieve it. The resulting guilt does not emerge from factual communication of risk, but from the unjust expectation that mothers must act alone in a structurally unsupportive environment [13]. As recent meta-analytic findings confirm, the impact of message framing cannot be separated from the broader social and economic landscape in which mothers operate [10].

Commercial exploitation of maternal emotion

Yet this nuanced understanding is obscured by the formula industry’s strategic exploitation of maternal guilt. The ‘guilt-free’ trope has historical roots: U.S. formula industry lobbyists in the early 2000s successfully pressured public health campaigns to soften risk-based breastfeeding messages, claiming they would ‘magnify maternal guilt’ [12]. Commercial formula marketing actively reframes breastfeeding advocacy as divisive or moralizing, while presenting formula as a comforting, “guilt-free“ alternative that is close to breastmilk [5], despite substantial evidence proving the opposite [32]. While rarely stated explicitly, the industry’s emotional framing reassures parents that choosing formula need not be a source of guilt, thereby neutralizing public health messaging and undermining structural support for breastfeeding. This is not passive advertising, but a strategic approach that co-opts maternal emotions and exploits moments of vulnerability. In addition, formula marketing undermines breastfeeding promotion by framing breastfeeding as a personal choice rather than a societal responsibility, and by obscuring its health risks [5]. This strategy not only weakens calls for structural support but also reshapes public perception, making formula appear neutral or empowering, despite its well-documented health implications. Previous research underscores the biological benefits of breastfeeding, reinforcing the high stakes of infant feeding decisions and thus deepening the emotional burden on mothers [1]. Formula companies then offer “guilt-free” messaging as a solution, which paradoxically reinforces the notion that guilt should be present. Psychological research explains this contradiction. Telling someone “don’t feel guilty” can trigger psychological reactance [33] or ironic processing [34], intensifying the very feelings being denied. Studies on the concept of implied accusation show that reassurances of innocence may provoke defensive reactions, especially when moral norms are at stake [35]. Rather than neutralizing guilt, “guilt-free” messaging underscores the moral stakes of infant feeding, thereby heightening maternal stress and discomfort. This helps explain why evidence-based breastfeeding promotion is so frequently labeled as harmful [5], while formula, an ultra-processed first food [36] that replicates only a fraction of human milk’s complexity [32], is presented as safe, nutritious, and unproblematic. This is the product of decades of industry marketing [5], normalized formula use in clinical care, and a social media ecosystem that promotes formula-friendly narratives through algorithmic targeting, influencer partnerships, and emotionally tailored messaging [37].

The same authors highlight how commercial actors have normalized the portrayal of formula feeding as an acceptable or preferable choice [5] by promoting messages that align with neoliberal ideals of autonomy and consumer freedom [12, 38]. This has contributed to the widespread perception of breastfeeding as a burdensome personal choice rather than a societal investment in maternal–child health. In contrast, global health frameworks highlight breastfeeding as a collective responsibility that requires supportive policies and social environments [1, 29]. Investigations show that formula companies use data-driven advertising to reach pregnant and postpartum women at moments of heightened vulnerability, often within hours of birth announcements or online activity related to infant care [14]. In many countries, including those with Code regulations, formula brands circumvent restrictions by using paid influencers, parenting forums, and private messaging groups to subtly and pervasively shape feeding norms. This digital marketing creates a landscape where breastfeeding-positive content is often marginalized, while formula is portrayed as empowering, science-based, and guilt-free [15]. Only the latest World Health Assembly (WHA 78) in May 2025 approved a resolution to develop, strengthen, and coordinate the regulation of digital marketing to protect infant and child health, and exhorted countries to invest in effective systems for monitoring and enforcement [39].

Finally, mothers are not passive recipients of formula marketing. Survey data from seven countries show that aggressive promotion is often perceived as intrusive and emotionally taxing. In a multi-country WHO study, nearly half of mothers reported exposure to CMF marketing, with television and social media being the most common channels, and unsolicited direct contact from formula companies was frequent in countries such as the UK and Vietnam [40]. Mothers reported that emotional appeals and marketing through trusted health professionals contributed to widespread perceptions of formula as equivalent to breastmilk. Similarly, reporting on interviews with mothers in Singapore, another study found that participants felt pressured by pervasive online marketing and described feeling confused or overwhelmed by conflicting messages [41]. Marketing tactics, including free samples and health claims, exploit mothers’ anxieties and erode confidence in breastfeeding, particularly in settings where skilled lactation support is lacking [42]. Together, these findings challenge the notion that mothers are persuaded by neutral information; instead, many describe these interactions as manipulative and misaligned with their needs for unbiased, supportive guidance. Yet, despite this global evidence, public discourse remains far more critical of breastfeeding advocacy than of formula industry tactics [12, 13].

Breastfeeding is deeply rooted in maternal-infant physiology and is inherently relational, requiring messaging that is transparent about risks, tailored to diverse contexts, and underpinned by robust systems-level support [1, 29]. Yet this transparency is often compromised by the strategic amplification of maternal guilt, a narrative leveraged by the formula industry to divert attention from systemic deficiencies [5]. Formula marketing subtly infiltrates prenatal, perinatal, and early parenting moments, targeting hospitals, healthcare providers, social media, and workplaces, particularly when institutional breastfeeding support is weak [43]. Prevailing Western media portrayals and policy discourse often individualize breastfeeding success or failure, obscuring broader structural barriers and reinforcing misplaced maternal responsibility [44]. Together, these analyses underscore that public health communication must challenge commercial framing and instead promote evidence-based messaging that recognizes breastfeeding as a public health imperative, not a personal lifestyle choice [1, 29].

What breastfeeding promotion can learn from this

Behavioral insights from other domains

Behavioral science has transformed how we approach public health challenges like smoking cessation, vaccination, and nutrition by emphasizing how environmental cues and non-conscious processes shape behavior [45]. Yet breastfeeding promotion has often been treated as an exception, overshadowed by the threat of hypothesized guilt-inducement and moral pressure [12, 13]. Despite rigorous evidence that behavioral economics tools, such as choice architecture and framing, can effectively improve vaccination uptake [46] and smoking cessation [47], breastfeeding campaigns remain hesitant to apply these insights or to run randomized controlled trials to determine what strategies work. Large-scale studies show that behavioral interventions often yield smaller effects when scaled [48], but they still offer meaningful, evidence-based avenues for promoting complex health behaviors.

Rethinking guilt and framing

Despite the behavioral insights offered by framing research in other areas of public health, the empirical base specific to breastfeeding remains very limited. The few studies that directly compare “risks of formula” with “benefits of breastfeeding” texts (though not true gain- or loss-framed RCTs) find that risk-based wording can be perceived as harsh or less trustworthy [49–51]. By contrast, qualitative and review evidence consistently show that mothers report guilt and shame around infant-feeding decisions when messages emphasize risk or moral responsibility, but these emotions are not unique to risk-framed public messaging. They are documented among both formula-feeding and breastfeeding mothers and often arise when personal feeding goals are unmet or when feeding becomes moralized [12, 52, 53]. Mothers often report negative emotional reactions such as guilt, shame, or anxiety when infant feeding messages are perceived as overly directive, judgmental, or pressure-laden, particularly when they conflict with their personal circumstances [52]. Many mothers report distress related to the decision to discontinue breastfeeding [54], including in cultures where breastfeeding rates are high [55]. Taken together, this suggests that maternal guilt may be driven less by framing per se and more by the moralization of infant feeding and the expectation that mothers shoulder responsibility in the absence of structural support [13].

Breastfeeding promotion can learn from other domains: where risk-based messages are culturally appropriate and effective, they should be used; where gain-framed messages are appropriate, they should be adapted. Both require robust structural support, including paid maternity leave, skilled lactation care as the default, and access to safe donor milk, to ensure that families are not left alone to navigate a decision that carries real health consequences. The global evidence is clear: no single message format fits all, but honest, context-sensitive risk communication is always possible [10].

Communicating risk with compassion

Reconciling compassion with honest communication is one of the most emotionally and ethically fraught challenges in breastfeeding promotion. All families deserve empathy, respect, and support, no matter how they feed their infants. But that truth must not become a rationale for strategic silence. In many other areas of public health, such as vaccination, seatbelt use, or smoking cessation, risks are communicated clearly despite the potential to cause discomfort or regret. We do not withhold cancer risk statistics or avoid discussing preventable harms because they may evoke strong emotions [46, 47]. In contrast, breastfeeding promotion operates within an unusually constrained rhetorical space. The formula industry has skillfully leveraged maternal guilt to such an extent that evidence-based risk communication is often perceived as judgmental or accusatory [5, 12, 13, 16]. It is also essential to distinguish between population-level health messaging and individual-level clinical care. Skilled lactation providers tailor their language to each family’s emotional and contextual realities, often using language that is gentle, deliberate, affirming, and responsive to parental needs [28]. Public health communication, by contrast, must operate at the population level and communicate precisely about risk to support informed decision-making and drive structural change. Systematic reviews confirm that emotions, social identity, and injunctive norms can deeply shape perceptions of infant feeding [56]. Yet public health campaigns continue to treat breastfeeding as an isolated lifestyle choice, rather than a behavioral outcome embedded in economic, cultural, and emotional structures [1, 29].

Avoiding clear communication about the risks of formula feeding for both infant and maternal health is not an act of kindness. It is a policy-level framing failure that undermines informed decision-making and is difficult to reconcile with core principles of behavioral public health. Honesty and compassion are not opposites: public health messaging must be capable of acknowledging real risks while advocating for structural support, shared responsibility, and nonjudgmental care. Loss-framed messages are not a universal solution, and guilt-inducing appeals should never be the goal, yet a broad tendency to avoid risk language is not well-supported by evidence. Transparent and context-sensitive communication, grounded in behavioral evidence and supported structurally, should be in scope for breastfeeding promotion.

Only by embracing both truth and empathy can we build a breastfeeding promotion framework that is evidence-based, emotionally intelligent, and structurally just.

Conclusion

Breastfeeding promotion as a public health priority must be supported by evidence-based behavioral strategies, rather than muted by commercial influence or rhetorical caution. Strategic silence around the risks of formula feeding, however well-intentioned, undermines informed choice and public trust.

Future research should prioritize randomized controlled trials and rigorous message testing to determine how different framing strategies perform across cultural and institutional contexts. Policy efforts must focus on regulating digital marketing practices, including algorithmic targeting and influencer sponsorships, while protecting public health communication from industry capture. At the level of practice, public health professionals and healthcare workers should be equipped to recognize commercial framing and to communicate risks clearly without invoking blame, maintaining a clear distinction between population-level messaging and individualized, compassionate clinical care.

The central implication is straightforward: responsibility for breastfeeding outcomes does not lie with mothers alone. It lies with the systems that shape infant-feeding environments. Acknowledging this responsibility is essential if breastfeeding promotion is to be effective, equitable, and worthy of public trust.

Author contributions

This is a single-authored manuscript.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.