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.
Perinatal regulations, promulgated by a state's Department of Public Health, govern hospitals that provide maternity and newborn services. Members of the MBC sat on a state committee formed to revise these regulations, and inserted language that would prohibit the distribution of commercial discharge bags to any mother in any Massachusetts hospital. Public testimony was heard on the draft of the revised regulations in fall 2005. Thirty-eight comments favored eliminating the bags. The eight comments favoring retaining the bags were put forth by some physicians and nurses, the International Formula Council, the Grocery Manufacturers Association, the Massachusetts Hospital Association, and Ross Products.21 In December 2005, the regulations were approved by the Massachusetts Public Health Council (PHC), and included a ban on hospitals' distribution of commercial discharge bags.22
Mitt Romney, at that time Massachusetts's governor, then asked the Public Health Council to rescind the formula-bag ban, stating that it interfered with mothers' choice.23 The council did. However, in a February meeting, three members of the Massachusetts Public Health Council objected to rescinding the bag prohibition and asked for a three-month study period to review the ban.24 During these three months, the MBC flew into action. We issued press releases and contributed to articles in the Boston Globe. We placed an ad in the widely read Boston Parents' Paper, wrote to legislators, and met with the Office of Administration and Finance. We created an online petition, collected 3,500 signatures that urged Governor Romney to reinstate the bag prohibition, and held a rally in front of the State House to present him with the petition. We obtained supporting statements from the Centers for Disease Control and Prevention (CDC), the state chapter of the American Academy of Pediatrics, the state chapter of the American College of Obstetricians and Gynecologists, the American Public Health Association, and the Massachusetts Public Health Association, all declaring their opposition to the distribution of formula bags.
In April 2006, Governor Romney removed a member of the Public Health Council who supported the bag prohibition.25 In May, in an attempt to bolster its support of commercial bag distribution, the International Formula Council commissioned a survey of 400 Massachusetts mothers, and claimed that 86 percent said that hospitals should be allowed to distribute these samples.26 That same month, days before the PHC meeting, Romney removed the remaining two supporters of the bag ban, thus ensuring that the regulation would not pass.27
Unbeknownst to the MBC at the time, Romney was actively courting Bristol-Myers Squibb—the parent company of Mead Johnson, maker of Enfamil formula—to build a $660 million facility in Massachusetts.28 Later in May, the PHC did not reinstate the bag prohibition, and the perinatal regulations reverted to their previous language stating that breastfeeding mothers can receive a commercial sample bag when prescribed by the physician or requested by the mother.29 Debate about the issue drew national attention; some leading Massachusetts hospitals voluntarily changed their policy, removing these marketing gimmicks from their maternity units.30
Much of this battle revolved around the language that opponents used to characterize why the ban should not take place. The International Formula Council, Governor Romney, and his staff and appointees claimed that the bag prohibition would deprive women of choice. In practice, what this means is that they have shifted the responsibility for the effects of potentially harmful products from the manufacturers to the consumers. We at the MBC learned to avoid using the word choice and to reframe the message as one about the harmful effects of marketing.
the empire strikes back
In July 2006, the MBC launched the national Ban the Bags Campaign. We put up a website, www.banthebags.org, with a wealth of information designed to help hospitals rid themselves of discharge bags. In March 2007, a week after the Wall Street Journal reported that more hospitals were abandoning hospital-based formula marketing,31 the formula industry responded with two websites of its own. Both sites are funded by the International Formula Council to defend hospital-based formula marketing. The site www.BabyFeedingChoice.org was registered by Kellen Communications. BabyFeedingChoice.org links to www.MomsFeedingFreedom.com, which presents itself as a grassroots site launched by a concerned mother in Massachusetts. In fact, MomsFeedingFreedom.com is registered to E Nilsson LLC (www.enilsson.com), an international Web consulting firm whose clients include the pharmaceutical giant Pfizer Inc. and Romney for President.32 The mother, Kate Kahn, is also a corporate communications strategist based in Boston whom E Nilsson LLC has employed to defend infant formula with PR spin.33 As if that weren't enough, legislation is in the works in Massachusetts to protect the distribution of formula bags. H2257 would legislate a mother's "right" to formula samples and equipment in the hospital, and thus protect industry interests.34MomsFeedingFreedom.com describes H2257 as a bill to "ensure moms' feeding choices are protected."35 If the bill becomes law, it will prevent the Department of Public Health from again trying to change the language of perinatal regulations to mandate eliminating the bags.
actions to eliminate discharge bags: what you can do
Actions outside of Massachusetts are well underway. The 11 public hospitals in New York City have eliminated the distribution of formula bags.36 Fifteen area hospitals in Portland, Oregon have done the same.37
Your opinion, too, counts. If the hospital where you delivered your baby distributes free formula bags, one of the first actions to take to eliminate them is to write a letter of complaint. Address multiple copies of the letter to the CEO/president of the hospital, the vice president of nursing, the nurse manager of the maternity department, and the chiefs of pediatrics and obstetrics, reminding them that you do not appreciate being made the target of a marketing campaign. (See sample letter above or go to www.banthebags.org. Under "Categories," click on "For Families," then on "Just Say ?No, Thanks.'") If you've recently had a baby, make sure you fill out any hospital satisfaction survey, and mention your displeasure at receiving or being offered such a bag. If you're expecting a baby, tell your nurse and pediatrician that you don't want the bag, and why you consider it unethical and a disservice to mothers. If a bag is offered to you, refuse it. Look around the maternity unit for other formula-marketing efforts, such as nurses wearing formula-brand name badges, and complain about these as well. If you already have a bag, return it to the hospital's maternity unit with a letter explaining that you would prefer that the nurses spent their time helping you and your baby learn to breastfeed rather than waste time handling the bags or interacting with formula salespeople on the unit.
Request that your state Department of Public Health look into and address the issue of mothers receiving sales pitches in hospitals within hours of giving birth. Join other mothers in protesting such practices. If you belong to a group such as MomsRising, ask that they begin a letter-writing campaign to all birthing hospitals in your state to eliminate formula discharge bags. If you haven't joined your state breastfeeding coalition, consider doing so, and/or ask that they pressure hospi-tals to cease marketing products to vulnerable new mothers. A list of state breastfeeding coalitions can be found at www.usbreastfeeding.org. (Click on "Information for State/ Territory Breastfeeding Coalitions" and then "State/Territory Breastfeed-ing Coalitions Directory.") Visit www.banthebags.org for information and support, and check out www.cafe press.com/banthebags for products you can use to get your message across.
one fewer commercial barrier to breastfeeding
While eliminating formula bags will not completely remedy our nation's low rate of exclusive breastfeeding, it will remove one more barrier to meeting the national goals set by Healthy People 2010 for exclusive breastfeeding: 60 percent at three months, and 25 percent at six months.38 Currently, only 224 US hospitals and birth centers have gone bag-free.39 We need more. All mothers deserve to receive respectful health-care services, and not be subjected to commercials for products peddled by those who should know better.
Marsha Walker, RN, IBCLC, lives and works in Weston, Massachusetts. She is the wife of one, mother of two, mother-in-law of two, grandmother of three, and dreams of being unemployed when all barriers to breastfeeding have been removed.
1. Y. Bergevin, C. Dougherty, M. S. Kramer, "Do Infant Formula Samples Shorten the Duration of Breast-feeding?," The Lancet 1, no. 8334 (21 May 1983): 1148-1151.
2. C. I. Dungy et al., "Effect of Discharge Samples on Duration of Breast-feeding," Pediatrics 90 (1992): 233-237.
3. D. A. Frank et al., "Commercial Discharge Packs and Breast-feeding Counseling: Effects on Infant-Feeding Practices in a Randomized Trial," Pediatrics 80, no. 6 (December 1987): 845-854.
4. J. M. Guise et al., "The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force," Annals of Family Medicine 1, no. 2 (July-August 2003): 70-78.
5. C. A. Eastham et al., "Differential Effect of Formula Discharge Packs on Breastfeeding by Maternal Race/Ethnicity," presented at the 133rd Annual Meeting and Exposition of the American Public Health Association (Philadelphia: 10-14 December 2005).
6. R. Pérez-Escamilla et al., "Infant Feeding Policies in Maternity Wards and their Effect on Breast-Feeding Success: An Analytical Overview," American Journal of Public Health 84, no. 1 (January 1994): 89-97.
7. L. E. Caulfield et al., "WIC-Based Interventions to Promote Breastfeeding among African-American Women in Baltimore: Effects on Breastfeeding Initiation and Continuation," Journal of Human Lactation 14 (1998): 15-22.
8. A. Wright, PhD, Sydney Rice, MD, Susan Wells, MD, "Changing Hospital Practices to Increase the Duration of Breastfeeding," Pediatrics 97, no. 5 (May 1996): 669-675.
9. B. J. Snell, PhD, CNM, "The Association of Formula Samples Given at Hospital Discharge with the Early Duration of Breastfeeding," Journal of Human Lactation 8, no. 2 (June 1992): 67-72.
10. A. Donnelly et al., "Commercial Hospital Discharge Packs for Breastfeeding Women," Cochrane Database System Review 2 (2000): CD002075.
11. K. D. Rosenberg et al., "Infant Formula Marketing through Hospitals: Impact of Commercial Hospital Discharge Packs on Breastfeeding," American Journal of Public Health (in press).
12. U.S. Department of Health & Human Services, "HIPAA Privacy Rule Guidelines: Marketing," 45 CFR 164.501, 164.508(a)(3) (3 April 2003): www.hhs.gov/ocr/hipaa/guide lines/marketing.pdf (accessed 5 November 2007).
13. U.S. Government Accountability Office, "Breastfeeding: Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect Against Misuse of WIC Name," GAO-06-282 (Washington, DC: 2006): 24.
14. V. Oliveira et al., "WIC and the Retail Price of Infant Formula," Food Assistance and Nutrition Research Report No. FANRR39-1 (Washington, DC: May 2004): 4; www.ers.usda.gov/Publications/FANRR39-1/.
16. U.S. Department of Health & Human Services, U.S. Food & Drug Administration, Center for Food Safety & Applied Nutrition, Office of Nutritional Products, Labeling & Dietary Supplements, "Health Professionals Letter on Enterobacter sakazakii Infections Associated with Use of Powdered (Dry) Infant Formulas in Neonatal Intensive Care Units" (11 April 2002, revised 10 October 2002): www.cfsan.fda.gov/~dms/inf-ltr3.html (accessed 6 November 2007).
17. Eric Flack, "Parents Say Hospital?s Baby Formula Led to Daughter?s Brain Damage," WorldNow Wave3 (5 November 2004): www.wave3.com/Global/story.asp?S=2531323&nav=0RZFSqE3 (accessed 6 November 2007).
18. S. Teske and S. T. Robbins, "Formula Preparation and Handling," in S. T. Robbins, L. T. Beker, Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities (Chicago: American Dietetic Association, 2004), 31-32.
19. U.S. Food & Drug Administration Press Release, "Abbott Voluntarily Issues a Nationwide Recall for One Lot of Alimentum, Two Lots of Similac Advance Liquid Infant Formula Ready-To-Feed 32-Ounce Plastic Bottles and One Lot of Hospital Discharge Kits" (15 September 2006): www.fda.gov/oc/po/firmrecalls/abbott09_06.html (accessed 6 November 2007).
20. Luz Chacon, "SB 1275 The Right to Informed Infant Feeding Choices," Breastfeeding Task Force of Greater Los Angeles (23 June 2004): www.breastfeeding?taskforla.org/advocacy/sb1275.htm (accessed 6 November 2007).
21. Massachusetts Breastfeeding Coalition, "How We Did It: Summary of Public Testimony 105 CMR 130.000 et seq.: Hospital Licensure Regulations" (2006): www.massbfc.org/news/testimony.html (accessed 27 November 2007).
22. Stephen Smith, Globe Staff, "Some Hospitals Forgo Baby-Formula Handout: State Considers Ban of Gift Bags," Boston Globe (8 May 2006): www.boston.com/business/health?care/articles/2006/05/08/some_hospitals_forgo_baby_formula_handout/ (accessed 27 November 2007).
24. Stephen Smith, Globe Staff, "Ban on Formula in Gift Bags for New Mothers Is Put on Hold," Boston Globe (22 February 2006): www.boston.com/news/local/massachusetts/articles/2006/02/22/ban_on_formula_in_gift_bags_for_new_mothers_is_put_on_hold/ (accessed 27 November 2007).
25. "Romney Overhauls Panel that Backed Ban on Baby Formula Giveaways," Boston Globe (20 May 2006): www.boston.com/news/local/massachusetts/articles/2006/05/20/?romney_overhauls_panel_that_backed_ban_on_baby_formula_giveaways/.
26. International Formula Council Press Release, "Massachusetts Mothers Overwhelmingly Oppose a Ban on Gift Bags with Infant Formula Samples: Almost Nine Out of 10 Mothers of Young Children Say State Should Not Restrict Distribution of Discharge Gift Bags in Hospitals" (11 May 2006): www.infantformula.org/newsroom_20060511.html (accessed 27 November 2007).
27. See Note 25.
28. Stephen Heuser, "Teamwork Landed Bristol-Myers: Government, Business, Colleges Came Together as a Sales Force," Boston Globe (3 June 2006): www.?boston.com/news/local/massachusetts/?articles/2006/06/03/teamwork_landed_?bristol_myers/ (accessed 27 November 2007).
29. See Note 25.
30. See Note 22.
31. Rachel Zimmerman, "Baby Goody Bags May Be On the Way Out," Wall Street Journal (27 February 2007): http://online.wsj.com/?article/SB117254916033220353.html (accessed 27 November 2007).
32. www.enilsson.com (accessed 27 November 2007).
33. "Who We Are," www.momsfeedingfreedom.com/index.php/home/legal/ (accessed 27 November 2007).
34. House No. 2257, "An Act Relative to Maternity Patients? Rights" (January 2007): www.mass.gov/legis/bills/house/185/ht02pdf/ht02257.pdf (accessed 27 November 2007).
35. www.momsfeedingfreedom.com/index.php/home/legal_alert_ma (accessed 4 December 2007).
36. New York City Health and Hospitals Corporation Press Release, "NYC Public Hospitals Eliminate Baby Formula Giveaways, Ban Promo Materials in Labor Units to Encourage Breastfeeding" (31 July 2007): www.nyc.gov/html/hhc/html/pressroom/press-release-20070731.shtml(accessed 27 November 2007).
37. Nursing Mothers Counsel of Oregon Press Release, "Portland, Oregon First City in the Nation to Eliminate Hospital Discharge Bags Containing Infant Formula Sample Packs" (7 August 2007).
38. U.S. Department of Health & Human Services, "Midcourse Review: Healthy People 2010: Chapter 16: Maternal, Infant, and Child Health" (19 December 2006): www.healthypeople.gov (accessed 11 November 2007).
39. Ban the Bags, "Bag-Free Hospitals and Birth Centers": www.banthebags.org/?page_id=17 (accessed 27 November 2007).