Ban the Bags

By Marsha Walker

The birth of a baby is a joyous event that everyone loves to celebrate with a gift. However, some gifts come with strings attached. Visits to the obstetrician yield a changing pad wrapped around a can of formula. Boxes and cases of formula arrive on the doorstep. Hospitals present new mothers with gift bags containing formula, while pediatricians' offices give new mothers a kit containing more formula, with instructions on how to use it to supplement a breastfed baby.

Which of the above "gifts" has been shown to be such an effective marketing tactic that it appears as an example in marketing textbooks? Answer: the gift bags given to new mothers as they leave the hospital. For decades now, mothers have received these "discharge bags" from formula companies. The bags have changed over the years, from pastel colors with cute bunnies and teddy bears to sleek black bags that look like briefcases, but the intent remains unchanged: to sell more formula. But to sell more formula, formula companies have to "sell" less breastmilk.

What discharge bags do and don't do

Research has shown that breastfeeding mothers who receive commercial discharge bags—even bags from which the cans of formula have been removed—are more likely to begin using formula earlier and to breastfeed for shorter periods.^1-9 Many parents and health-care providers don't appreciate the effects of formula-marketing strategies, and say they are too smart to be manipulated. But multiple studies show an association between the distribution of free commercial-formula discharge bags and lower rates of breast-feeding. Whether or not these bags actually contain samples of formula, mothers who receive them have difficulty adhering to the medically recommended regimen of exclusive breastfeeding for a child's first six months. At all points measured in that period, the rate of exclusive breastfeeding of mothers who have received discharge bags is lower.^10,11

While parents and health-care providers are deluded into thinking that discharge bags are merely gifts, in the Health Insurance Portability and Accountability Act of 1996, the federal government treats the distribution of infant formula bags as a form of marketing.¹² Formula companies also consider the bags a marketing tool, and note that most US hospitals provide formula discharge packs to new mothers.¹³ Hospitals distribute the bags not because they have any therapeutic value or because the formula has been specially selected for an individual baby, but because the hospitals are paid by formula companies to do so. This payment can be in the form of free formula for use in a hospital's nursery, free educational programs for nurses, free supplies or equipment in other areas of the hospital, discounts on drugs, or even cash.

Sampling—getting the product directly into the hands of the consumer—?is an especially effective form of marketing. Formula companies know that when a trusted physician, nurse, or hospital hands a new mother a discharge bag containing a sample of formula, the mother will assume that that brand is sanctioned by the health-care provider and is safe to use. Because the health system has implicitly endorsed a particular brand of formula, the vast majority of mothers will continue to purchase that brand after being discharged.

This brand loyalty means big bucks for the formula manufacturer over the long term. Nor are the bags really "free"—mothers who buy name-brand formula (such as Similac or Enfamil) pay 33 to 66 percent more than for store-brand or generic formula.¹⁴ Store-brand or generic formula is all made by the same company, PBM Nutritionals, but labeled with a particular store's brand. Formula-feeding mothers bear the brunt of this price gouging, as much of the cost of infant formula goes to pay for its marketing. While each discharge bag costs the formula company less than $7, one year of name-brand formula can cost up to $2,000.¹⁵ Families can pay an additional $700 or more per year for the name brands compared to generic brands—a 1,000 percent profit for formula makers, and a hefty price for the "free" bag.

Nor is the practice of distributing formula-containing discharge bags necessarily safe. Much of the formula in these bags is powdered, increasing an infant's risk of being fed a contaminated product (powdered infant formula is not sterile).¹⁶ Infants have been sickened from the use of this gift.¹⁷ Most hospitals lack stock-control procedures and do not record the lot numbers of formula or formula bags.¹⁸ When a recall occurs, such as the recent recall of Ross Products formula and discharge bags,¹⁹ the hospital has no way of knowing which patients may have received a recalled, defective, or contaminated product.

efforts to eliminate discharge bags

Many hospitals have become dependent on the free products and services provided by formula companies. While their patients pay the price in cash and potentially adverse health outcomes, most hospitals insist that this practice is beneficial to their patients. Because efforts to persuade hospitals to the contrary had proven ineffective, breastfeeding advocates in California attempted to pass legislation regulating the marketing that formula companies can conduct in hospitals.²⁰ When this failed, the Massachusetts Breastfeeding Coalition, in the spring and summer of 2005, took advantage of an opportunity to amend the state perinatal regulations to eliminate the distribution of formula bags in Massachusetts hospitals.