The saga continues. I wrote a letter last month to a department chairperson
in regards to their consideration of accepting a monetary offer from a
formula company to distribute to each prenatal patient a packet of
information. I am not printing their letter to me [you'll be able to figure
out what they wrote], but have included below my response to them.
You have my permision to copy or paraphrase portions of this letter to
respond to similar situations you may encounter.
Dear Dr. xxxx,
Thank you for your timely response to my letter of 11/16. Your letter made
several points that were thought provoking and certainly merit further
discussion.
As you mention in your letter, women are exposed to a tremendous amount of
advertising, regardless of whether we contribute to this by distributing the
formula companies literature or not. I propose however, that by virtue of
the fact that the Center for Women's Health is respected health care group,
the advertising materials it distributes carry a different weight with
consumers, than say, what is distributed at the local supermarket. The
supermarket contains a wide variety of choices for the population it serves.
For example, people expect to go to the supermarket and be able to buy
cigarettes, for even though smokers are in the minority in our area, the
supermarket's primary role is to make a profit, and consumers recognize
this.
The mission of Women's Health Center is to provide optimum health care to
women (and their offspring). The expectation of the patients is that our
primary concern is their well being, so what the Center distributes, whether
samples, coupons or literature, it also implicitly endorses. The
expectation is that we are distributing items that are in our patients best
interest, and not, like the supermarket, that we distribute them on the
basis of returning a profit for doing so. This is the basis for the trust
in the doctor - patient relationship.
In terms of maternal choice, which you mention several times in your letter,
I agree with you that it is our job to provide the best information about
health choices. I have reservations that distributing advertising materials
from a company that stands to make a profit from the choice, is providing
the "best information", however. Beyond being in conflict with the
International Code of Marketing Breastmilk Substitutes1 [developed by WHO
and UNICEF] it puts The Women's Health Center further from "Baby Friendly"
status, a designation that would make our hospital stand out favorably from
its competitors.2
The issue of support for mothers who have chosen to give their infant
formula is actually more complex, because traditionally at our hospital, we
haven't routinely addressed the other aspect involved with formula feeding
which is preparation. I'm sure you are aware of the different ways standard
formula is sold - powder, concentrate, and ready to feed - and of the
different costs of each. The cost of "ready to feed" is especially
prohibitive and many bottle feeding parents opt to use powder or concentrate
to save money. However, we don't give these parents an opportunity to learn
and demonstrate competence with formula preparation. This deserves to be
addressed, since correct formula preparation and its safe storage is
imperative for the infant's well being. In addition, many formula feeding
moms mention they are making their choice to involve the father of the baby,
this would be an excellent opportunity to have the nursing staff
"in-service" the father as well.
Finally, your letter brings up the issue of guilt. We are dealing here with
adult women. Surely, no one would suggest that we have so little respect for
their decision-making ability that we should withhold scientific data from
them in the interest of appearing neutral when it is not a neutral decision
they are making? We would be doing women more of a service to remove
perceived barriers to breastfeeding [returning to work, lack of confidence,
little support] so that more mothers could make a decision they are truly
comfortable with - without regrets.
So why not distribute the formula companies materials for them - especially
since they are going to give us money for doing it?
Formula companies are looking to increase their market share by providing
formula to breastfeeding women. When formula is used to supplement or
replace breastfeeds it has the effect of shortening the duration of
breastfeeding.3, 4, 5, 6, 7 [This is the research I alluded to in my first
letter.] Further, the formula companies have been "less than open" about
disclosing that they are gathering patient info for this purpose. It is
many a hospital that thought they were providing "free" items as a courtesy
that discovered afterwards that it's breastfeeding moms were being sent
cases of unsolicited formula.
Much of the information the formula companies seek to distribute tends to
blur the distinction between breastmilk and formula. Breastfeeding provides
significant health benefits for both mother and baby. With breastfeeding as
the standard, by comparison formula not only falls short but also is
associated with health risks. [Increase in otitis media, increase in
gastroenteritis, increase in URI, etc.] Breastmilk and formula are NOT
equivalent.
Because formula feeding is associated with health risks, we as health care
professionals should not be taking part in its promotion. Any information
that we display or distribute on behalf of the formula company implies our
endorsement of that product. We especially should not be accepting funds to
distribute these materials.
May I suggest as an alternative that The Women's Health Center contact the
various car seat manufacturers and offer their literature a spot in a
hospital designed literature package in exchange for a donation to the
"literature and lecture fund". Car seats are a necessity for ALL babies
and they are an item with proven health benefits. A car seat is a purchase
that is made prenatally, and would be a great service as "hand-me-downs" are
discouraged due to recalls and wear.
A hospital designed literature package could include breastfeeding and
feeding information as well as "What to expect during your pregnancy" info -
I'm sure the residents or medical students could do a good job with writing
this. Pediatrics may be interested in contributing to this project as well.
We give new parents lots to read after the baby is born which is precisely
when they DON'T have any time left to read it!
I'm sure that some people see this question as a simple "hand out some
papers for some money" issue and don't understand why I've objected so
strongly to something that on the surface seems so benign. It really is
though, a bigger issue. It involves integrity, children's health and patient
trust - all too valuable to lose.
I would be glad to help The Women's Health Center with the production of a
hospital designed prenatal information packet. Please let me know how I can
be of assistance.
Sincerely,
Gail S. Hertz, MD, IBCLC
Department of Pediatrics
1. International Code of Marketing of Breast-Milk Substitutes WHO & UNICEF
1981 ISBN 92 4 154160 1
2. Protecting, Promoting and Supporting Breast-feeding. The Special Role of
Maternity Services. WHO & UNICEF 1989 ISBN 92 4 156130 0
3. Adair LS, Popkin BM, Guilkey DK. The duration of breast-feeding; how is
it affected by biological, sociodemographic, health sector and food industry
factors? Demography 1993 Feb;30(1)63-80
4. Loughlin HH et al. Early termination of breastfeeding; identifying those
at risk Pediatrics 1985 Mar;75(3)508-13.
5. Blomquist, H., et al. "Supplementary feeding in the Maternity Ward
Shortens the Duration of Breast Feeding" Acta Paediatr 83:1122-1126, 1994
6. Snell BJ, et al. "The association of formula samples given at hospital
discharge with the early duration of breastfeeding". J Hum Lact 7:129-4,
1991
7. Wright A, Rice S, Wells S. "Changing hospital practices to increase the
duration of breastfeeding". Pediatrics 97:669-75, 1996
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