Massachusetts Breastfeeding Coalition

What’s wrong with those cute formula “gift” bags?

(article updated 03/28/06)

For decades, formula companies have given out attractive diaper bags to maternity patients at discharge, and parents often appreciate receiving a free gift. But these free gifts are a marketing technique used to boost sales of formula, and evidence now shows that these free gifts hurt breastfeeding.

About 80% of baby formula sold in the United States is made by big pharmaceutical companies. The bags represent part of the growing trend of “cradle to grave” exposure to marketing at the expense of public health, another example of which is soft-drink sponsorship of school programs. In the case of formula, the pharmaceutical industry is intruding into patients’ hospital rooms to peddle a product known to be linked with adverse health outcomes. A recent paper in the Journal of the American Medical Association decried the influence of the pharmaceutical industry as an unnecessary intrusion into the doctor-patient relationship (Brennan T et al.).

These “gift bags” are such an effective marketing technique that they are used as an example in marketing textbooks. The bags are not really free. They cost the companies less than $7 each, but a year of brand-name baby formula costs parents up to $2,000, a substantial portion of which goes to marketing. The bags only advertise the most expensive brands of formula, costing parents about 66% more than store brands. Hospital-based marketing clearly pays off, with most parents buying the same brand they got in the hospital. Thus, the bags affect all parents, no matter how they choose to feed their baby.

Internal documents from the formula industry illustrate that the bags are an effective marketing tool, increasing sales of formula at the expense of breastfeeding. This finding is consistently shown by medical research, and confirmed in a recent GAO report. The key to the bags’ success is their distribution by health care providers, providing implicit endorsement of bottle-feeding. As noted in the sales training manual for formula-maker Ross, “A nurse who supports Ross is like another salesman.”

Another key to the bags’ success is the perception that they will save families money. However, poor women are at the highest risk of the poor health outcomes that can be prevented by breastfeeding. Since the formula in a gift bag represents less than a week’s worth of feedings, it will hardly help stretch the budget of low income families. In fact, Boston Medical Center, which cares for a high proportion of low income women, stopped distributing these bags almost a decade ago, because it considers the practice unethical. Every container of formula lists a toll-free number which families can call to receive free bags, coupons, or samples.

Exclusive breastfeeding for the first six months of life is the current recommendation from the American Academy of Pediatrics, the American Academy of Family Physicians, and the World Health Organization. There is abundant scientific evidence that early introduction of formula is linked with adverse health outcomes even for babies who are also breastfeeding. These outcomes are best summarized in the AAP’s recent position statement on breastfeeding, and on the AAFP’s position statement on breastfeeding.

There is also ample evidence that when breastfeeding mothers get corporate-sponsored bags, they are more likely to start using formula, even when the bags do not contain formula. Specifically, the bags reduce the number of women exclusively breastfeeding at all times measured between zero and six months of age (Click here to review the references in the medical literature about this effect.)

Hospitals’ distribution of free products from formula companies is a gross violation of the 1981 WHO International Code on Marketing of Breastmilk Substitutes,which has over 100 signatory countries. The US agreed to an amendment of this code in 1994, and the US Surgeon General makes reference to it in the HHS Blueprint for Action on Breastfeeding The federal government’s HIPAA legislation also defines this practice as marketing, and there is a certain liability attached to dispensing such free products without proper precautions.

Furthermore, because of the adverse health outcomes linked with non-exclusive breastfeeding, these bags may actually cost families money, in terms of medications and time lost from work to care for a sick child, not to mention paying for formula. Ball and Wright, in 1999, documented the significant excess health care costs of formula-fed children in the first year of life.

Politicians such as Massachusetts governor Mitt Romney claim the bags are necessary to preserve women’s freedom to choose how to feed their babies. But aggressive formula marketing undermines the choice of the 74% of women who choose breastfeeding, by setting them up for breastfeeding failure. In addition, research shows that most women make their feeding choice during pregnancy, not when they leave the hospital with a gift bag.

Hospitals should market health, and nothing else.

For more information, see our “Fact Sheet” on Massachusetts proposed ban on formula company discharge bags, our Frequently Asked Questions about the ban, and our Petition, to support it.