by Heidi Hauser Green
November 04, 2011
Updated November 24, 2015
Infant formula manufacturers may refer to their discharge bags as “infant feeding support kits,” but these artfully packaged “freebies” have one purpose: secure more infant formula customers. Bent on increasing sales, infant formula makers have, for decades, provided free formula to birthing facilities. In return, members of the hospital staff distribute discharge kits containing formula samples to every new mother who gives birth at that hospital (regardless of their feeding choice) as a means of securing brand loyalty. In this quid pro quo exchange, hospitals are incentivized to make sure that every mother-baby dyad leaves the hospital with a bag of formula samples in hand, even though many leading health authorities—including the World Health Organization and the U.S. Surgeon General—have urged providers “not [to] serve as advertisers for infant formula … [or] implicitly promote infant formula.”
The American Academy of Pediatrics (AAP) recommends that mothers exclusively breastfeed their babies for the first six months, but just 19 percent of U.S. babies receive only breast milk from ages 0–6 months. There are many reasons why mothers might stop breastfeeding sooner than they had planned, but among them is early use of infant formula. Health care providers agree that giving a newborn a bottle or two of formula in the first days after birth can keep a mother from producing enough milk to nourish her baby, and can alter a newborn’s ability to suckle effectively at the breast.
With a growing body of research showing the risks of early formula use and the benefits of hospital practices that protect breastfeeding (such as rooming-in, skin-to-skin contact, and exclusive breastfeeding), many hospitals nationwide are opting out of giving free formula samples and have stopped distributing discharge bags.
A history of discharge kits
Infant formula was originally developed as a means of feeding babies who did not have access to breast milk, but it quickly evolved into a moneymaking venture with manufacturers seeking to convince mothers that formula was not only comparable to breast milk but more convenient. Such claims drew the attention of the American Medical Association (AMA), and in 1929 the AMA began requiring that the formula industry market their products only to physicians and others in the medical community (and not to the public), claiming that health care providers should be responsible for “indications and directions for formula use.”
For much of the twentieth century, formula companies focused their attention on winning over physicians by using strategies that included seminars, promotional materials, and financial support for scientific meetings, medical research, education, and other events. In the 1970s, however, manufacturers turned their attention to consumers, with Nestlé taking the lead in countries outside the U.S., despite widespread criticism of its direct-to-consumer sales tactics. Despite the fact that formula use posed serious health risks (given the lack of clean water) for babies born in Africa, Asia, and Latin America, Nestlé sent its sales representatives door-to-door, dressed in nurses uniforms, to sell infant formula. When Nestlé entered the U.S. formula market in 1988, direct marketing to new and expectant parents was the company’s priority. Soon, its leading competitors Abbott Nutrition (Similac) and Mead-Johnson (Enfamil), adopted similar strategies including giving new mothers a useful and attractive diaper bag imprinted with the company name and logo and chock full of infant formula samples, coupons, advertisements, brochures, and other baby items. The bags became an integral part of an overall marketing strategy designed to inundate pregnant women and new mothers—even those who told their health care providers they intended to breastfeed—with ready-to-feed alternatives to breast milk and questionable breastfeeding information.
In 2006, efforts to stop hospitals from distributing formula samples to new mothers began to take shape. A Rhode Island hospital made the elimination of the practice and the potential effect on breastfeeding rates the subject of a nationally funded grant. The following year, breastfeeding proponents in neighboring Massachusetts launched the “Ban the Bags” campaign, which has evolved into a national effort and has helped eliminate discharge bags from Massachusetts, Rhode Island, Washington, D.C., Delaware, and Maryland, as well as various hospitals and health systems across the U.S. In spite of anti-bag efforts, Mead-Johnson contracted with the AAP as recently as 2012 for the group’s symbol to appear on free formula bags—both inside and out. It is a seeming endorsement of formula-feeding by a group that otherwise is well-known for encouraging mothers to breastfeed. The relationship attracted criticism from many, including the Academy of Breastfeeding Medicine (ABM), which called on the AAP to terminate its relationship with Mead-Johnson (as of November 2015, the AAP has taken no action).
How discharge kits send the wrong message
Research shows that receiving a discharge bag containing infant formula makes it more likely that new mothers will discontinue breastfeeding sooner than the recommended six months. As Dr. Gail Herrine, director of Temple University’s postpartum unit explains, it makes it more likely that new mothers, worried about “perceived low supply” or “difficulty latching,” may opt to give formula temporarily without realizing that it can “lead to problems with breastfeeding,” such as low supply for the mother and, for the infant, problems suckling effectively. By encouraging early formula supplementation, such marketing practices interfere with the establishment of a full milk supply, which can make it difficult for mothers and babies to continue breastfeeding. Milk production is the result of the mother making a “supply” of milk in response to her baby’s “demand.” Perceived insufficient milk supply is a leading cause of early cessation of breastfeeding. A mother worried about her supply should feed her baby more often (perhaps with the help of a International Board Certified Lactation Consultant (IBCLC) rather than give her baby infant formula.
Parents who do decide to formula-feed often will use whatever product the hospital gives them, says Anne Merewood, PhD, MPH, IBCLC and director of The Breastfeeding Center at Boston Medical Center, since pediatricians typically advise against arbitrarily switching formulas. That means that the hospital is effectively advertising a specific brand of formula by giving samples to mothers. “Maybe the hospitals don’t realize [they are marketing formula]” she explains, “but that’s what’s happening.”
Discharge packs containing infant formula send “the wrong message to new moms,” agrees Jennifer Aist, supervisor of the lactation program at the Baby Friendly-designated Providence Alaska Medical Center in Anchorage.
“We aim to promote wellness, and breast milk is the best food for babies,” says Aist. “Delivering free formula at hospital discharge or in the mail two weeks later when mom’s resources are at their lowest is not the right thing to do. This has led mothers to believe that their bodies are not capable of feeding their young.”
A continued effort to ban the bags
While the practice still occurs all too often, the number of hospitals giving out formula company discharge bags has decreased in recent years, due in large part to efforts by the Massachusetts Breastfeeding Coalition, sponsor of the “Ban the Bags” campaign, the U.S. Centers for Disease Control and Prevention (CDC), and other public health groups. The percentage of hospitals and birth centers distributing discharge packs dropped from 73 percent in 2007 to just 32 percent in 2013. While Rhode Island (with just seven birthing hospitals) was alone in having less than one-quarter of hospitals distribute the bags in 2007, 24 states and territories met that mark in 2013. Currently, four states—Rhode Island, Massachusetts, Delaware, and Maryland—have banned hospital distribution of infant formula bags.
The decrease in discharge pack distribution may also be the result of greater participation by hospitals in the Baby-Friendly Hospital Initiative (BFHI). Formula distribution violates the World Health Organization’s International Code of Marketing of Breast-milk Substitutes—which hospitals must adhere to in order to be awarded the baby-friendly designation. While just 2.9 percent of U.S. births occurred in baby-friendly facilities in 2007, that rate has increased to 14.8 percent in 2015. More than 300 U.S. facilities have been designated baby-friendly and many more facilities are currently working to achieve the designation.
Writing as a senior author of a previous study of discharge pack distribution, Merewood suggests that the downward trend is reflective of a new ethical look at a behavior that was thought to be benign, one in which doctors and hospitals are getting less input and taking fewer free samples from pharmaceutical companies.
The International Formula Council (IFC) defends formula discharge packs as “infant feeding support kits” that provide necessary information for mothers, and states that criticism of the practice distracts from the real obstacles to long-term breastfeeding. But “Ban the Bags” counters that such packs “undermine public health”—the very mission of hospitals—and are “costly, unethical, and ultimately, bad for [health care] business.” Merewood agrees, stating frankly that “[t]he bottom line is that hospitals should not be marketing formula.”
Research shows that what health care facilities need to give new mothers when they leave the hospital is not infant formula samples and coupons, but information about breastfeeding basics–signs of hunger, position and latch tips, and suggestions for getting started, as well as contact information for local breastfeeding experts should mothers encounter problems after they leave the hospital. Mothers need to know that most breastfeeding issues or complications can be resolved with adequate knowledge and support.
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