Infant Formula Marketing in Public Hospitals:
An Outdated and Unethical Practice
Public Citizen
April 2016
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
2
Acknowledgements
This report was written by Kristen Strader, Campaign Coordinator for Public Citizen’s
Commercial Alert Campaign, with contributions from Katherine Kehres, intern at Public Citizen.
Public Citizen acknowledges and thanks leaders of Ban the Bags campaign, the North Carolina
Breastfeeding Coalition, the New York City Department of Health and Mental Hygiene, Jackson
Memorial Hospital, the Centers for Disease Control and Prevention, University of Alabama
Birmingham Hospital and all hospital staff who responded to the survey for contributing their
stories and data for this report.
About Public Citizen
Public Citizen is a national non-profit organization with more than 400,000 members and
supporters. We represent consumer interests through lobbying, litigation, administrative
advocacy, research, and public education on a broad range of issues including consumer rights
in the workplace, product safety, financial regulation, worker safety, safe and affordable health
care, campaign finance reform and government ethics, fair trade, climate change, and
corporate and government accountability.
Public Citizen’s Commercial Alert works to keep the commercial culture within its proper
sphere, and to prevent it from exploiting children and subverting the higher values of family,
community, environmental integrity and democracy.
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th
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P: 202-588-1000
F” 202-588-7799
www.citizen.org
© 2016 Public Citizen
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Contents
Executive Summary………………………………………………………………………………………………………… 2
Introduction……………………………………………………………………………………………………………………. 5
Formula Marketing in Low-Income Communities…………………………………………………………… 7
Efforts to Improve Breastfeeding Rates by Enforcing the WHO Code…………………………….. 9
Case Studies…………………………………………………………………………………………….……………………… 10
a. Jackson Memorial Hospital……………………………………………………………………………. 10
b. New York City Department of Health and Mental Hygiene: Latch on NYC…….. 10
c. University of Alabama Birmingham Hospital…………………………………………………. 11
Methodology…………………………………………………………………………………………………………………… 12
Results…………………………………………………………………………………………………………………………….. 13
Conclusion………………………………………………………………………………………………………………………. 13
Appendix A……………………………………………………………………………………………………………………… 15
Appendix B……………………………………………………………………………………………………………………… 16
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Executive Summary
Public hospitals are generally operated by county and municipal governments in order to
provide health care services to underserved communities that may have limited access to care
elsewhere. A large proportion of public hospital patients are low-income, uninsured, or covered
by Medicaid, according to surveys of metropolitan public safety net hospitals. Public hospitals
often serve as training institutions, so they generally employ best practices in health care.
1
In 2013, Commercial Alert published the report, “Top Hospitals’ Formula for Success.” In that
report, we determined that the elimination of company-sponsored infant formula discharge
bags has become standard among the nation’s top ranked hospitals.
This follow-on report examines the trends in infant formula promotion and breastfeeding
information available to new mothers in public hospitals. Since those who use public hospitals
are most often low-income with few or no other options for care, public hospitals play a vital
role in introducing first food and, hopefully, providing breastfeeding support void of corporate
influence.
The results of our analysis of the largest public hospitals in the United States are consistent with
our previous research on top-ranked hospitals in the United States. The vast majority of public
hospitals are also following best practices in public health by supporting breastfeeding and
ending the distribution of company-sponsored formula discharge bags and other promotional
materials.
We found that overall, public hospitals are overwhelmingly following the trend in eliminating
the distribution of infant formula company-sponsored discharge bags and promotional
materials. Of the 62 hospitals from which we received responses, 95 percent (59 out of 62) are
completely free of all forms of infant-formula marketing. One hospital does not distribute
formula sample bags, but does distribute promotional coupons and the two hospitals that do
distribute formula sample bags have plans to stop. We requested responses from 65 hospitals.
Three hospitals were non-responsive and are not included in our final analysis.
Recommendations
Given the documented impact that breastfeeding support and formula sample distribution has
on breastfeeding rates among low-income patients, we recommend that public hospitals that
have not ended the practice do so immediately. Due to resource limitations, we were unable to
determine the status of every public hospital in the country.
Formula companies should follow the World Health Organization’s International Code of
Marketing of Breast-milk Substitutes and stop marketing formula in all health care facilities.
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Introduction
________________________________________________________________________
“There is a multi-billion dollar battle going on
over every infant’s first meal.”
– Kimberly Seals Allers
2
________________________________________________________________________
People love receiving “free” products, whether a sample of a new energy bar at a grocery store
or an aesthetically appealing box of formula samples with polka dots and a blue ribbon on the
packaging. Free samples are especially appealing when one is struggling financially. But
although presented as “free,” infant formula samples are far from it.
For years, formula companies such as Abbott (producer of Similac), Mead-Johnson (Enfamil),
and Nestle (Gerber Good Start), have used nurses and doctors in hospitals to advertise their
products unofficially. When hospital staff distributes company-sponsored discharge bags to
new families, they tacitly communicate that they expect breastfeeding to fail, that using
formula is a healthy choice and that they endorse a particular brand of formula. This unethical
practice contradicts hospitals’ core mission of advancing health.
There is little doubt that formula giveaways and in-hospital marketing affects breastfeeding
practices. The American Journal of Public Health published a study which provided evidence
that women who received commercial hospital discharge packs were less likely to breastfeed
exclusively for up to 10 weeks than those who did not receive the pack.
3
To protect new mothers, consumer and public health organizations have initiated campaigns
targeted at hospitals to remove infant formula marketing in the form of free samples and
company-sponsored literature.
The global medical community widely recognizes that exclusive breastfeeding for the first six
months of life is physically and psychologically healthiest for both mother and baby in the short
and long-term.
4
This notion is supported by data from a myriad of sources and studies from a
diverse community of health and research professionals. Each mother’s breastmilk uniquely
meets their infant’s needs and can naturally aid in recovery from illnesses. Studies show that
infants who have been breastfed experience lower rates of childhood obesity, asthma, ear
infections, type 2 diabetes, and many other health problems than those who have not been
breastfed.
5
Economically, choosing to breastfeed saves the average family between $1,200 and
$1,500 per year in infant formula,
6
sick days from work, and medical bills for sick infants and
children as they age.
7
Breastfeeding creates an emotional connection for mothers and babies
and can lower the risk of certain types of breast cancer for mothers.
8
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Healthy People 2020, a Centers for Disease Control and Prevention (CDC) initiative created to
determine the most urgent health problems facing Americans and how to address them,
identifies increased rates of breastfeeding as a national priority.
9
The larger goals of Healthy People 2020 are to:
Attain high-quality, longer lives free of preventable disease, disability, injury, and
premature death.
Achieve health equity, eliminate disparities, and improve the health of all groups.
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across all life
stages.
10
Breastfeeding is proven to have a multitude of positive effects on mothers and their babies,
however, many mothers who are capable of breastfeeding do not receive the support
necessary for success. A disproportionate number of low-income and minority mothers are
formula-feeding their newborns, or supplementing breastfeeding with formula, in part because
of misleading marketing and inaccurate information about its effects.
The World Health Organization’s (WHO) Code of Marketing of Breast-Milk Substitutes states
that manufacturers of infant formula should not provide samples of products to pregnant
women and mothers.
11
The code was established in 1981 and prohibits the marketing of
formula in hospitals, yet many hospitals in the United States continue to distribute company-
sponsored discharge bags filled with samples, coupons and promotional literature.
The birthing hospital that a family chooses provides the first introduction to infant food and
support for mother and baby. Since those who use public hospitals are most often low-income
and lack breastfeeding support once they leave the hospital, public hospitals have a unique
responsibility to provide comprehensive breastfeeding support and commercial-free care.
Breastfeeding Rate Disparities
A lack of economic and social resources creates a barrier to breastfeeding support for mothers
in low-income areas. First food deserts are geographic areas where mothers do not have
sufficient access to breastfeeding support, including educational resources, employer support,
and supportive cultural attitudes about nursing in public.
12
As a result of these persistent
barriers, breastfeeding rates among low-income mothers are lower than those of higher-
income mothers who have easier access to breastfeeding resources needed for success.
CDC data shows that a large disparity exists between white and African-American breastfeeding
rates. In 2000, 47.4% of African-American mothers initiated breastfeeding compared to 71.8%
of white mothers and 77.6% of Hispanic mothers. Likely due to an increase in hospital
breastfeeding support and a cultural shift towards normalizing breastfeeding, rates of
breastfeeding initiation overall increased by the year 2008 among all races, but the disparity
continues to prevail. In 2008, 58.9% of black women and 75.2% of white women initiated
breastfeeding.
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Disparities in rates also prove to be dependent on socio-economic status. The CDC reported
that in 2006, higher-income
women were breastfeeding
at a rate of 74% while only
57% of low-income women
were breastfeeding.
13
In
figure 3, PIR represents
poverty income ratio. It is
clear that among all races,
those with high PIR
breastfeed at significantly
higher rates than those with
low PIR.
New York City Department of
Health and Mental Hygiene
(NY DOHMH) reports that
among mothers who gave
birth between 2009-2011 in New York City, 31% of those with a college education exclusively
breastfed at eight weeks after the baby was born compared to 23% of mothers with less than a
high school education, further supporting the notion that economic opportunity impacts a
mother’s chance of breastfeeding.
14
Formula Marketing in Low-income Communities
There is reason to believe that targeted marketing of infant formula toward low-income and
minority mothers has played an important role in widening the gap in breastfeeding rates
between the poor and the wealthy, and between women of different races. Although there has
been an upward trend in breastfeeding overall in the last twenty years, rates among African-
American women remain lower than those of white and Hispanic women.
Low-income women face unique challenges which formula marketers are able to exploit. As
Kimberly Seals Allers, journalist and advocate for breastfeeding support in African American
communities, explains, “When formula is advertised with perks, it creates the appearance that
mothers who breastfeed are missing out on free items that their families need too. Free
diapers, free wipes, free pizza for your dinner and maybe even a new TV. Under new WIC
regulations, breastfeeding mothers, get more food items than formula feeding mothers, but
when you drive down the street and store after store offer necessities as freebies for making
your infant formula purchases at their store, the message is clear: Formula feeding pays off.”
15
"Women think they are simply choosing to breastfeed or formula-feed but there's little
conversation about how cultural and economic forces shape the choices that we have. We
often end up just responding to the marketing messages we receive or the cultural myths that
travel through families and communities," says Seals Allers, who also directs the First Food
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Friendly Communities Initiative, a national accreditation program for breastfeeding supportive
communities.
16
WIC and Cost
The Special Supplemental Program for Women, Infants, and Children (WIC) has been cited as
promoting the use of formula
17
and thus impacting the lower rates of breastfeeding among
low-income populations. As the largest purchaser of formula in the country, WIC has a
significant impact on the infant formula market and the long-term brand loyalty of WIC
recipients once they are no longer receiving assistance.
WIC provides supplemental foods and infant formula to mothers in need of assistance at no
cost. Formula companies contract with the program to provide large rebates at a low cost to
taxpayers.
18
Each state awards a contract to the company that offers the lowest bid and in
exchange receives exclusive rights as the only formula provider for WIC in that state.
19
Formula companies experience spillover effects from holding a contract with WIC. Shelves in
grocery stores are stocked with more of the brand supplied by WIC, which encourages non-WIC
recipients to purchase that brand since it is predominately on display. In some cases, the non-
WIC brands may be in low supply and difficult to find on a regular basis.
20
Additionally, brand
loyalty and a fear of switching formulas encourage parents to continue purchasing the WIC
brand once they are no longer receiving the vouchers.
Breastfeeding rates among WIC recipients across the United States are lower than non-WIC
recipients. In 2007, 67.5% of women receiving WIC reported having ever breastfed compared to
the national average of 75%. Of the same sample, 33.7% of WIC recipients reported continuing
breastfeeding into the sixth month compared to the national average of 43%.
21
Further, New York Department of Health and Mental Hygiene data reveals that low-income
mothers in New York City who receive WIC are less likely to breastfeed for at least six months
than mothers who do not receive the supplemental assistance. In 2011, 38 out of 100 NYC WIC
recipient mothers were exclusively breastfeeding for at least six months compared to 58 out of
100 mothers in NYC who did not receive WIC.
22
WIC has recently taken steps to improve breastfeeding rates and reduce the use of formula
among WIC recipients, offering larger food packages for breastfeeding mothers and peer
counselling among other supportive services.
23
In 2007, WIC began offering three different
food packages. Fully breastfeeding families receive the largest package with the most variety,
partial breastfeeding families who supplement with formula receive a smaller and less varied
food package with some formula, and fully formula-feeding families receive the smallest food
package with formula. Offering larger food packages to families who breastfeed is meant to
incentivize families to choose breastfeeding over formula feeding.
24
A 2012 study revealed that
the WIC policy change in package offerings had no significant impact on rates of exclusive
breastfeeding.
25
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Courtesy of CDC
http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
Given that being on WIC is associated with lower breastfeeding rates, it is especially important
that public hospitals be part of the solution and provide early breastfeeding support without
influence from formula companies.
Efforts to Improve Breastfeeding Rates by Enforcing the WHO Code
Regardless of the formula companies’ marketing tactics, breastfeeding rates are improving and
rates of formula feeding are decreasing overall.
26
According to the CDC, the percentage of U.S.
infants who had ever been breastfed reached 77% in 2013
27
compared to 72.6% in 2003.
28
Although there has been an upward trend in rates of breastfeeding overall in the last twenty
years, rates among African-American women lag far behind those of white and Hispanic
women.
According to the CDC, the disparity between African-American and white breastfeeding rates
has decreased from 24 percent in 2000 to 16 percent in 2008.
29
The closing gap is a positive
step forward, but a large gap
continues to exist. Economic
and systemic barriers
manifest into a lack of
available resources, such as
the elimination of
breastfeeding programs in
low-budget hospitals, a lack
of reimbursement for
outpatient breastfeeding
support, inability to afford
unpaid maternity leave, lack
of clean and private lactation
accommodations, and
cultural challenges.
30
Efforts to improve breastfeeding rates overall and particularly among low-income communities
have ranged from cultural shifts to hospital policy changes, spurred in part by government and
grassroots campaigns like the Baby-Friendly Hospital Initiative (BFHI),
31
Ban the Bags
32
and
Public Citizen’s Infant Formula Marketing Campaign.
33
Among all hospitals both private and public, rates of distributing company-sponsored discharge
packs have decreased sharply over the last decade. CDC’s Maternity Practices in Infant
Nutrition and Care survey (mPINC) determined that rates of distribution are consistently
decreasing. The percentage of hospitals in the United States distributing discharge packs
declined from 72.6% in 2007 to 65.8% in 2009 and from 54.5% in 2011 to 31.4% in 2013.
34
Many public hospitals have begun or completed the Baby-Friendly hospital certification
process, an initiative created in partnership by the WHO and United Nations Children Fund
(UNICEF). Step 6 of the certification process requires hospitals to “give infants no food or drink
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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other than breast-milk, unless medically indicated,” a provision which prohibits the distribution
of company-sponsored discharge bags and formula samples.
Case Studies
The following case studies reflect the successful efforts of public hospitals and one government
agency to raise breastfeeding rates and enforce the WHO Code by eliminating the distribution
of company-sponsored infant formula samples from healthcare facilities.
Jackson Memorial Hospital
The Women’s Hospital at Jackson Memorial, a public hospital and a renowned teaching facility
in Miami, Florida, is part of Jackson Health System, an integrated health care delivery system
that includes six hospitals throughout Miami-Dade County. On average, about 6,500 babies
annually are born at Jackson Health System facilities – the Women’s Hospital at Jackson
Memorial, Jackson North Medical Center and Jackson South Community Hospital. As a public
hospital system, Jackson receives support from the community and maintains a special
commitment to providing equal resources to all mothers at all times.
Jackson Health System began its journey towards Baby-Friendly designation in the spring of
2014. The first step was educating staff on the benefits of breastfeeding and Baby-Friendly
standards as part of the “dissemination phase.” Additionally, Jackson Health System replaced all
company-sponsored discharge bags with breastfeeding education discharge bags that are
offered to all new mothers. In an effort to promote exclusive breastfeeding and support their
Baby-Friendly goal, Jackson decided to remove logos and coupons related to formula.
While Jackson Health System had consistently maintained fairly high breastfeeding initiation
rate (women breastfeed in the hospital), exclusive breastfeeding rates have risen since they
implemented these efforts. Support for Baby-Friendly and breastfeeding has been strong as
Jackson Health System continues in the Journey to Designation.
New York City Department of Health and Mental Hygiene: Latch on NYC
In May of 2012, New York City launched a campaign to encourage supportive breastfeeding and
the elimination of infant formula marketing in both private and public hospitals. Hospitals were
asked to voluntarily commit to adopting practices that support breastfeeding. Heavily endorsed
by health care organizations, such as the New York State Department of Health, Academy of
Pediatrics, and Academy of Family Physicians, Latch on NYC was successful in getting hospitals
to sign on.
35
The commitment requires that hospitals:
Enforce the New York State hospital regulation to not supplement breastfeeding infants
with formula feeding unless medically indicated and documented on the infant’s
medical chart
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Posters were placed in hospitals and subway
stations to raise awareness of the benefits of
breastfeeding.
Photo Courtesy of Latch on NYC
Restrict access to infant formula by hospital staff,
tracking infant formula distribution and sharing
data on formula distribution with the health
department
Discontinue the distribution of promotional or
free infant formula
Prohibit the display and distribution of infant
formula promotional materials in any hospital
location
36
During the campaign announcement at Harlem Hospital,
Commissioner Thomas A. Farley explained that the
distribution of infant formula marketing is harmful to
new mothers and babies. “When babies receive
supplementary formula in the hospital or mothers
receive promotional baby formula on hospital discharge
it can impede the establishment of an adequate milk
supply and can undermine women’s confidence in
breastfeeding,” he said. “With this initiative the New
York City health community is joining together to support mothers who choose to breastfeed.”
37
As a result of New York City’s aggressive efforts to improve breastfeeding support in hospitals,
91.1% of New York hospitals do not distribute discharge packs containing infant formula
marketing materials according to 2013 CDC data.
38
University of Alabama Birmingham Hospital
39
In order to improve rates of breastfeeding and better support new mothers, the University of
Alabama Birmingham Hospital (UAB) made the decision to adopt the Ten Steps to Successful
Breastfeeding and seek Baby-Friendly status. In 2012, UAB completely eliminated infant
formula samples and discharge bags. The transition was not met with resistance from patients.
Rather than distributing bags, UAB will be distributing a safe to sleep t-shirt for babies to
promote their “back to sleep” campaign.
As a result of banning formula bags and adopting the Baby-Friendly steps, rates of exclusive
breastfeeding went from 28% in 2011 to 76% in 2015. Sylvia Edwards, lactation consultant at
UAB, said she does not believe that eliminating infant formula samples from public hospitals
should be any more challenging than elimination from private hospitals. Since public hospitals
are often one of the only resources for breastfeeding support and education among low-
income patients, it is imperative that they do not send messages of formula endorsement.
Edwards believes that it takes a cultural shift and a commitment at the administrative level to
help mothers be successful with breastfeeding. “New mothers already struggle with
confidence,” she said. “When hospitals don’t comply with the WHO Code, they are undermining
a mother’s ability to breastfeed successfully.”
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Although only two hospitals in Alabama have officially been designated Baby-Friendly, 26 are
on the journey to get there. A mentorship program connects representatives from the hospitals
that have completed the journey with those who are seeking certification to exchange advice
and support for making the transition.
Methodology
To determine the extent to which public hospitals permit or prohibit infant formula marketing,
we surveyed the largest public hospitals in the country.
This study primarily relies on data gathered through a survey conducted by Public Citizen in
October of 2015. Part of the research was based on publicly available information from the Ban
the Bags campaign website and the North Carolina Breastfeeding Coalition’s Golden Bow
Awards page.
Ban the Bags, an initiative originally started in July of 2006, maintains a public list of hospitals
through the nation that have chosen to eliminate the distribution of company-sponsored infant
formula discharge bags.
40
As of October 2015, 914 hospitals and birth centers have banned the
bags. The status of 10 of the hospitals included in this study were informed by the Ban the Bags
list.
North Carolina Breastfeeding Coalition administers Golden Bow Awards to hospitals that meet
the following criteria:
1. No commercial infant formula gift bags are distributed. Note that removing formula
from commercial bags before distribution does not suffice.
2. All gifts to maternity patients are free of infant formula advertising of all varieties
(coupons, samples, infant feeding information published by a formula company, etc).
3. A 24-hour supply of infant formula is given at discharge ONLY if it is left over formula
from the baby’s cart and/or is medically indicated by the infant’s health care provider.
41
North Carolina Breastfeeding Coalition’s public database of hospitals that have received the
Golden Bow Award informed the status of four hospitals in our study.
Hospitals were chosen based on size. Most of those selected were generated from Beckers
Hospital Review’s list, “50 Largest Public Hospitals in America.”
42
According to Beckers, “figures
are based on CMS cost report data analyzed by American Hospital Directory. Data are for short
term acute-care hospitals, critical access hospitals and children's hospitals. For the purposes of
this list, AHD data were stratified to include the following "type of control" categories:
governmental hospital district; governmental city; governmental city-county; governmental
county; governmental federal; governmental other; and governmental state.”
43
Two of the
hospitals on this list do not have maternal or newborn services, leaving us with an initial sample
size of 48 hospitals.
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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In order to account for states not represented in the initial 48 largest public hospital list and to
provide a higher level of confidence in our results, we surveyed 17 additional hospitals. These
hospitals are the largest public hospitals with maternal services in the states that were not
originally included in Becker’s list. This list was obtained from the American Hospital
Association’s Free Hospital Look-Up service.
44
Of the 65 hospitals that Public Citizen surveyed, three were non responsive and are not
included in our analysis, leaving us with a total of 62 hospitals.
The survey was administered via phone and email with hospital representatives from
departments of lactation services, labor and delivery, postpartum, gynecology and obstetrics,
and/or mother education departments. At least five attempts were made to collect a response
from each hospital. The survey respondents included RN lactation consultants, nurse managers,
patient care managers and other personnel with direct knowledge of the hospitals’ maternity
unit policies and practices.
Results
An overwhelming majority (59 of 62) of the public hospitals that we surveyed do not distribute
company-sponsored infant formula bags or formula marketing of any kind. Two hospitals
distribute bags and other promotional materials. Representatives from both of the hospitals
that distribute bags said that they have plans to end the distribution of bags and are in process
of going Baby-Friendly. One hospital that we surveyed does not distribute formula sample bags,
but does distribute coupons.
Some hospital representatives who we spoke with over the phone proudly declared that they
were either certified Baby-Friendly or working their way towards being Baby-Friendly. The
general attitude from representatives was a sense of pride associated with banning company-
sponsored infant formula discharge bags.
Conclusion
Public hospitals have a unique responsibility to encourage breastfeeding and provide objective
care free of corporate influence. Low-income women often lack breastfeeding support
resources once they leave the hospital and return home due to cultural barriers and a lack of
resources. Public hospitals can act as a source of education and breastfeeding support when
first food deserts are an obstacle for many low-income women.
Our survey demonstrates that public hospitals are adopting practices which better support new
mothers and their infants. In the “Top Hospitals’ Formula for Success: No Marketing of Infant
Formula” report that Public Citizen released in October of 2013, we concluded that 82 percent
of U.S. News’ Honor Roll best hospitals had eliminated company-sponsored infant formula
discharge bags. Public hospitals are keeping up with the trend among top hospitals in sending
the message that hospitals should only market health, not generate profits for formula makers.
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The trend towards infant formula marketing elimination and the adoption of the Baby-Friendly
initiative in public hospitals is a step in the right direction towards supporting all mothers in
breastfeeding and closing the gap of breastfeeding rates among white and African-American
mothers. Efforts to encourage hospitals to eliminate formula marketing through letter writing,
state-wide campaigns, petition delivery and public pressure have resulted in significantly
decreased rates of formula sample bag distribution.
Hospitals that still distribute company-sponsored infant formula sample bags are behind in the
medical field and are putting infants and families at risk. We recommend that all hospitals
follow this trend and provide health care free of corporate influence.
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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APPENDIX A
Public Citizen Survey on Infant Formula and
Breastfeeding Information and Materials in Hospitals
1. Name and Address of Hospital:
2. Name, Title and Email of Contact Person Responding to Survey:
3. Does your hospital maintain an official policy on distributing infant formula company-
provided discharge packs or other formula materials to new mothers?
___ Yes ___No
4. Does the hospital distribute any of the following items to patients free of charge? (select all
that apply)
•Infant formula samples
•Nipples, bottles, coupons or other formula-related materials
•Discharge packs/bags with formula names or logos of displayed
•Breast pumps
•Other informational/promotional materials related to infant formula and/or
breastfeeding (specify):
5. Comments or additional information:
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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APPENIX B
Distribution of Formula Company-Sponsored
Discharge Bags/Materials
Survey Results
Hospital
State
Source
UAB Hospital
Birmingham
AL
Public Citizen
Hunstville
Hospital
AL
Public Citizen
UAMS Medical
Center
AR
Maricopa
Integrated
Health System
AZ
Public Citizen
DCH Regional
Medical
Center
CA
Ban the Bags
University of
Southern
California
Medical
Center
CA
Ban the Bags
University of
California San
Francisco
Medical
Center
CA
Public Citizen
University of
California San
Diego Medical
Center
CA
Ban the Bags
Kaweah Delta
Hospital
CA
Public Citizen
University of
California
Davis Medical
Center
(Sacramento)
CA
Public Citizen
Santa Clara
Valley Medical
Center (San
CA
Ban the Bags
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Jose)
Santa Clara
Valley Medical
Center (San
Jose)
CA
Ban the Bags
Sharp
Grossmont
Hospital (La
Mesa)
CA
Public Citizen
Memorial
Hospital
Central
CO
Ban the Bags
Memorial
Regional
Hospital
(Hollywood)
FL
Public Citizen
Jackson
Memorial
Hospital
FL
Public Citizen
Lee Memorial
Hospital
FL
Public Citizen
Broward
General
Medical
Center
FL
Public Citizen
Sarasota
Memorial
Hospital
FL
Public Citizen
Medical
Center of
Daytona
Beach
FL
Public Citizen
Grady
Memorial
Hospital
GA
Public Citizen
Navicent
Health
GA
Public Citizen
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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WellStar
Kennestone
Hospital
GA
Public Citizen
Gwinnett
Medical
Center
GA
Public Citizen
Hilo Medical
Center
HI
Public Citizen
University of
Iowa Hospitals
and Clinics
IA
Public Citizen
Kootenai
Health
ID
Public Citizen
University of
Illinois
Hospital
IL
Public Citizen
Eskenazi
Health
IN
Public Citizen
University of
Kansas
Hospital
KS
Public Citizen
University of
Kentucky
Albert B.
Chandler
Hospital
KY
Public Citizen
University
Health
Shreveport
LA
Public Citizen
Cambridge
Health
Alliance
MA
Public Citizen
University of
Michigan
Hospitals and
Health Centers
MI
Ban the Bags
Hennepin
County
Medical
Center
MN
Public Citizen
University of
Missouri
Hospital and
MO
Public Citizen
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
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Clinics
University of
Mississippi
Medical
Center
MS
Ban the Bags
Carolinas
Medical
Center
NC
NC Golden Bow Award
University of
North Carolina
Hospitals
NC
NC Golden Bow Award
New Hanover
Regional
Medical
Center
NC
NC Golden Bow Award
Cape Fear
Valley Medical
Center
NC
NC Golden Bow Award
University
Hospital
NJ
Public Citizen
University of
New Mexico
Hospital
NM
Ban the Bags
Bellevue
Hospital
Center
NY
Ban the Bags
Upstate
University
Hospital
NY
Public Citizen
University
Hospital of
Brooklyn
NY
Public Citizen
Westchester
Medical
Center
NY
Public Citizen
Kings County
Hospital
Center
NY
Ban the Bags
Stony Brook
University
Medical
Center
NY
Ban the Bags
Elmhurst
NY
Ban the Bags
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
20
Hospital
Center
Nassau
University
Medical
Center
NY
Public Citizen
Ohio State
University
Wexner
Medical
Center
OH
Public Citizen
MetroHealth
Medical
Center
OH
Public Citizen
Norman
Regional
Health System
OK
Public Citizen
OHSU Hospital
OR
Greenville
Memorial
Hospital
SC
Baby Friendly USA
Jackson-
Madison
County
General
Hospital
TN
Public Citizen
Erlanger
Baroness
TN
https://www.babyfriendlyusa.org/find-
facilities
Memorial
Hermann
Southwest
Hospital
TX
Ban the Bags
Ben Taub
General
Hospital
TX
Public Citizen
Parkland
Hospital
TX
Ban the Bags
John Peter
Smith Hospital
TX
Public Citizen
University of
Utah Health
Care Hospital
and Clinic
UT
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
21
VCU Medical
Center
VA
Ban the Bags
Princeton
Community
Hospital
WV
Public Citizen
Cheyenne
Regional
Medical
Center
WY
Public Citizen
1
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2
Seals Allers, K. (2017). The Big Let Down—How Medicine, Big Business and Feminism Undermine Breastfeeding.
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3
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Best for Babes (2013). Science You Can Use: Moms in “First Food Deserts” are hard pressed to breastfeed.
http://www.bestforbabes.org/science-you-can-use-moms-in-first-food-deserts-are-hard-pressed-to-breastfeed/
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McDowell, M., Wang, C., Kennedy-Stephenson, J. (2008). Breastfeeding in the United States: Findings from the
National Health and Nutrition Examination Survey, 1999-2006. Centers for Disease Control and Prevention.
http://www.cdc.gov/nchs/data/databriefs/db05.htm
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New York City Department of Health and Mental Hygiene (2015). EPI Data Brief: Breastfeeding Disparities in New
York City. http://www.nyc.gov/html/doh/downloads/pdf/epi/databrief57.pdf
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Mocha Manual (2014). Forget the who code. It’s the street code that undermines mothers in Detroit.
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detroit/
16
Adewunmi, B. (2012). Why are black women less likely to breastfeed?. The Guardian.
http://www.theguardian.com/lifeandstyle/2012/jul/23/kimberly-seals-allers-breastfeeding-advocate
Public Citizen Infant Formula Marketing in Public Hospitals: An Outdated and Unethical Practice
22
17
Kent, G (2006). WIC’s promotion of infant formula in the United States. US National Library of Medicine National
Institutes of Health. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481608/
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Kent, George (2006). WIC’s Promotion of infant formula in the United States. International Breastfeeding
Journal. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481608/
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Oliveira, V., Frazao, E., Smallwood, D. (2011). The Infant Formula Market: Consequences of a Change in the WIC
Contract Brand. United States Department of Agriculture. http://www.ers.usda.gov/media/121286/err124.pdf
20
Oliveira, Victor (2011). Winner Takes (Almost) All: How WIC Affects the Infant Formula Market. United States
Department of Agriculture. http://www.ers.usda.gov/amber-waves/2011-september/infant-formula-
market.aspx#.VuLtSlsrK71
21
U.S. Department of Health and Human Services (2011). The Surgeon General’s Call to Action to Support
Breastfeeding. http://www.ncbi.nlm.nih.gov/books/NBK52681/table/ratesof.t1/?report=objectonly
22
New York City Deoartment of Health and Mental Hygiene (2015). EPI Data Brief: Breastfeeding Disparities in New
York City. http://www.nyc.gov/html/doh/downloads/pdf/epi/databrief57.pdf
23
Best for Babes (2012). Did changes in WIC packages make you choose exclusive breastfeeding? A new study
investigates. http://www.bestforbabes.org/did-changes-in-wic-packages-make-you-choose-exclusive-
breastfeeding-a-new-study-investigates/
24
Id.
25
Wilde, P., Wolf, A., Meena, F., Collins, A. (2012). American Society for Nutrition.
http://ajcn.nutrition.org/content/early/2012/07/23/ajcn.112.037622.full.pdf
26
Centers for Disease Control and Prevention (2015). Breastfeeding among U.S. Children Born 2002-2012, CDC
National Immunization Surveys. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
27
http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf
28
Centers for Disease Control and Prevention (2003). Breastfeeding Rates by Age among Children Born in 2003.
http://www.cdc.gov/breastfeeding/data/NIS_data/2003/age.htm
29
Centers for Disease Control and Prevention (2013). Progress in Increasing Breastfeeding and Reducing
Racial/Ethnic Differences-United States, 2000-2008 Births.
http://www.cdc.gov/breastfeeding/resources/breastfeeding-trends.htm
30
Best for Babes (2013). Science You Can Use: Moms in “First Food Deserts” are hard pressed to breastfeed.
http://www.bestforbabes.org/science-you-can-use-moms-in-first-food-deserts-are-hard-pressed-to-breastfeed/
31
Baby-Friendly USA (2016). Baby-Friendly Hospital Initiative. https://www.babyfriendlyusa.org/about-us/baby-
friendly-hospital-initiative
32
Ban the Bags (2016). http://banthebags.org/
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Public Citizen (2016). http://www.citizen.org/infant-formula
34
Centers for Disease Control and Prevention (2015). Maternity Practices in Infant Nutrition and Care (mPINC)
Survey. http://www.cdc.gov/breastfeeding/data/mpinc/
35
Farley, T.. Latch on NYC: A hospital-based initiative to support a mother’s decision to breastfeed. New York City
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description.pdf
36
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“Latch on NYC” Initiative to Support Breastfeeding Mothers. http://www.nyc.gov/html/doh/html/pr2012/pr013-
12.shtml
37
New York City Department of Health and Mental Hygiene (2012). New York City Health Department Launches
“Latch on NYC” Initiative to Support Breastfeeding Mothers. http://www.nyc.gov/html/doh/html/pr2012/pr013-
12.shtml
38
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mothers by state CDC National Survey of Maternity Practices in Infant Nutrition and Care (mPINC).
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39
"Interview with Sylvia Edwards of University of Alabama Birmingham Hospital." Telephone interview. 13 Oct.
2015.
40
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