I use the following as a handout when I lecture on the hazards of infant
formula. Please feel free to see if there is any idea in this that may be of
help to those who are faced with the absurdity of enticing mothers to deliver
at your hospital because they get free discharge packs with formula. The
president of your hospital, its CEO, and its board of directors should all be
informed of this practice as well as the hospital's ethics committee.

Ridding Your Hospital
of Formula Dependency

 The health care system has traditionally been a major conduit for the
promotion of infant formula use. The medical sanctioning of artificial feeding
of infants starts at obstetrical visits with pregnant women being signed up
for formula clubs, distribution of coupons for infant formula, starter packs
of artificial baby milk, and literature from infant formula manufacturers.
This commercial pressure continues in the hospital with commercial discharge
packs, gifts and services to the staff, and large amounts of cash paid to the
hospital to accept the free formula supplies used to feed non-breastfed
babies. Some hospitals sell their pre-admission list of pregnant women to
formula companies. These practices make it difficult to fully implement the
Ten Steps to Successful Breastfeeding upon which the Baby Friendly Hospital
Initiative is based. How can you remove some of these barriers to
breastfeeding?

1. Perform a survey of your institution or agency, logging all the items and
services provided by infant formula companies. Look for the following: are
cans of formula visible to patients, is formula company literature displayed
or given to mothers, are there formula club sign-up sheets at the reception
desk, are mothers given formula gift packs, literature or videos, do formula
companies provide food for staff in-service education programs, does your
hospital have a contract with a formula company specifying a cash payment in
return for distribution of formula discharge packs to breastfeeding women, are
mothers given cards to remind them to ask for the discharge pack before
leaving the hospital, are staff expenses paid by formula companies to attend
continuing education programs, sporting events, parties, etc., has your agency
received architectural services from a formula company? Keep track of these
practices for several months to produce a log. Ask if any of these products or
services have any therapeutic value to patients. Ask for research-based data
showing that these products or services benefit mothers and babies. Put a
dollar value on these items and services to illustrate why formula is so
expensive to the mothers who pay for all of these practices. Consider forming
a task force to halt such practices.

2. Check your institution or agency's policy on selling or marketing products
to patients. Since discharge packs and gift packs are forms of marketing,
employees may be unknowingly violating institutional policy.

3. Check your job description. Does it mention marketing of products as a
requirement of the job? If not, do not do it. Does your job description or any
document you signed as a condition of employment prohibit marketing of
products? If not, you may wish to add this to it for patient protection. If it
does, then avoid giving out discharge packs from commercial interests.

4. Obtain the mission statement of the hospital, agency, or program where you
work. Does it mention promotion of health as a goal? If so, ask how marketing
formula promotes a health goal. Does it mention marketing commercial products
as a means to this goal? If not, avoid using formula company items.

5. Look at the hospital licensure regulations for your state. Do they permit
marketing of products to patients? New York and Massachusetts have specific
sections in their licensure codes which forbid giving discharge packs
containing formula to breastfeeding mothers unless the mother requests them or
the physician prescribes them. Talk with your state department of public
health as well as the Department of Health Care Quality, informing them of
these practices and asking if these are permissible. Contact your state
attorney general's office and ask if this type of marketing is ethical or
legal in your state.

6. If you are a nurse, contact your state nurse's association regarding the
marketing of products to patients. Does this fall within the scope of practice
of a nurse? Does it fit in with the ethical practice of the nursing
profession? If not, ask them for a statement to this effect for your use.

7. If you belong to a professional organization, check if it has publications
on the ethical practice of your profession. Does it contain any statement or
reference on marketing products to patients?

8. Contact both the ethics committee and your hospital's attorney and ask for
a statement on the legality and ethical principles behind the issue of the
hospital endorsing products for financial gain, either directly by accepting
infant formula at no cost, or indirectly by accepting cash grants and
additional services. Remind colleagues that no other product is received by
health care institutions at no cost, in amounts that fulfill the needs of the
entire hospital.

9. Ask if your hospital sells pre-registration lists of its maternity patients
to infant formula companies. If it does, request that the institution refrain
from this practice as it is knowingly increasing health care costs. Ask your
state public health department, state hospital association, and state attorney
general if this practice is ethically sound

10. Has your unit been approached to change its breastfeeding policy to allow
distribution of formula-containing discharge packs? Formula companies have
offered cash to maternity units for "educational" purposes in return for
changing established unit policy to require giving breastfeeding mothers
commercial discharge packs. This type of bribe can set a dangerous precedent
whereby formula companies may pressure cash-strapped maternity units to change
breastfeeding management guidelines to increase the chances that a mother
would need or want to supplement her baby with formula.

11. Has your unit been in-serviced or provided with a document from a formula
company stating that formula supplementing increases breastfeeding duration?
Be cautious of disinformation and misinformation. Supplementing decreases milk
production and can lead to infant illness, as breastmilk with anti-infective
properties is replaced with artificial baby milk with no disease protection.
Before recommending supplementation with formula, check with your medical
director, ethics committee, and hospital attorney regarding ramifications of
changing unit policy in order to use interventions which knowingly can lead to
health risks for infants.

12. Obtain a written copy of your institution's vendor policy. Since formula
company representatives frequently do not follow hospital vendor policies that
are in use throughout the rest of the hospital, ask that formula companies be
held to the same standards. In order to reduce the chances of compromising
patient care, ask that the vendor policy include language that applies to
formula company representatives and prohibits:
o vendor visits without an appointment
o visits to staff not identified as the vendor contact person
o in-services conducted without a documented request from the vendor contact
person or the maternity unit
o in-services conducted by vendors on topics not directly related to the
vendor's product
o dispensing commercial patient education material
o vendor access to nurses' stations, patient care areas, outpatient clinics,
hallways, lounges, cafeterias, and hospital libraries
o staff from accepting material gifts, gratuities, meals, entertainment, free
goods, vendor services, or personal expenses. Vendors should be prohibited
from offering these items to any staff, consultants, or attending personnel

13. Ask your purchasing department if your hospital has a contract with a
formula company. Request a written copy of this. Ask if any other units have a
contract with a supplier to accept free goods in return for marketing their
products. Ask what the cash is used for and who is accountable for it. All
other units pass on the cost of food to the insurer. Why doesn't the nursery?

© 1998 Marsha Walker, RN, IBCLC

Marsha Walker, RN, IBCLC
Weston, Massachusetts