A Case for Hospitals:An Evidence-Based Approach

Maryland Breastfeeding Coalitionhttp://www.mdbfc.org

Ban-The-Bags Maryland!

National Ban-the-Bags Initiative…What’s involved?

The hospital staff does not provide formula company give-away (diaper) bags, coupons, sample formulaIncludes breastfeeding mothers and babiesIncludes non-breastfeeding babies

The hospital staff does not discharge infants with any amount of formula

Discharge gifts may be provided if they do not contain formula or formula marketing

When Health Care Providers hand out formula, they implicitly endorse formula, including the particular brand

that is distributed

Vision:

The Maryland Breastfeeding Coalition’s vision is to end routine distribution of commercial formula sample packs to mothers at birthing hospitals in Maryland

All birthing hospitals in the states of Rhode Island and Massachusetts, and all public hospitals in NYC are now bag free. Let’s have Maryland be the next state to achieve this status.

DHMH Model Hospital Breastfeeding Policy Recommendations

Launched November 2012 to assist all Maryland birthing hospitals in a quality improvement process to strengthen and improve maternity care practices related to breastfeeding.

All birthing hospitals in Maryland are encouraged to become “Maryland Best Practices Hospitals” or to go “Baby Friendly”

Are you on board?

DHMH Model Hospital Breastfeeding Policy includes the recommendation that:

“Hospitals should not accept free formula, advertisements, or formula coupons for use in the hospital or distribution to breastfeeding mothers.”

Joining the Maryland Breastfeeding Coalition’s initiative to Ban the Bag will meet one of the recommendations of this DHMH program.

Evidence-based:

Several studies among different populations have demonstrated a significant negative impact of commercial formula pack distribution on breastfeeding success.

Decrease duration of breastfeeding

Median duration of exclusive breastfeeding for those receiving a discharge pack containing materials designed to be consistent with the WHO Code was shown to be longer compared to those receiving the commercial discharge pack

60 days vs. 42 days respectively o P=0.004

Frank et al, 1987

Increase Hospital visits:

Infants whose mothers received discharge packs consistent with the WHO Code had lower rates of re-hospitalization compared to those who received commercial discharge packs during the first 4 months post partum

1% vs. 14% respectively

Frank et al, 1987

Decrease initiation of breastfeeding

WIC mothers who received commercial discharge packs were 6.5 times less likely to initiate breastfeeding than those who did not receive the bag

OR:0.22 CI (0.07, 0.67)

Caulfield at al, 1998

Decreased continuation of breastfeedingWIC women who received commercial formula bags were 6

times less likely to continue breastfeeding at 7-10 days compared to those who did not

OR:0.17 CI (0.07,0.44)

Caulfield at al, 1998

Earlier Supplementation:Discharge packs with formula: Supplement at mean: 4.5 weeks Discharge packs without formula: Supplement at mean: 7.1

weeks

At 3 weeks, 39% of those who received formula gift packs supplemented vs. 19% of those who had no gift pack

Wright, 1996. Snell, 1992

Drive breastfeeding:Mothers who received formula or coupons in their discharge

packs were significantly less likely to be breastfeeding at all one month later compared to those who had none

78.7% vs. 90.8% respectivelyP=0.01

Wright et al, 1996

Current Recommendations:American Academy of Pediatrics:

Exclusive breastfeeding for the first six months Breastfeeding with complementary foods to 12 monthsContinuation of breastfeeding beyond 12 months as desired by

mom and baby

Surgeon General’s 2011 Call to Action to Support Breastfeeding encourages Health Care facilities to establish maternity care practices that are fully supportive of breastfeeding.

Current RecommendationsCDC Healthy People 2020 Objective:

Increase proportion of infants ever breastfed to 81.9%

Increase the proportion of infants who are exclusively breastfed at 6 months to 25.5%.

The Joint CommissionExclusive breast milk feeding in the

hospital is now one of their Perinatal Care core measures.

Why the Fuss?

Besides never being recalled,

Breast milk has many benefits…

Just a few of the benefits from breastfeedingHealth Benefits to Baby:

Reduces incidence of acute otitis media, gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, childhood leukemia, SIDS

There are no studies showing a health benefit of formula

Health Benefits to Mother:Reduces incidence of type 2 diabetes, breast cancer, ovarian

cancer, postpartum depression

Ip S et al, 2007Bai, 2009

Reduces cost to families:Mothers who receive a particular brand of formula in a

hospital are more likely to stick with it after discharge.Brand name formulas cost families $700 more a year than store

brands.

Families following optimal breastfeeding practices could save more than $1,200–$1,500 in expenditures for infant formula in the first year alone

Oliveira 2004, Ball TM 1999

AHRQ Cost Analysis savings

If 90% of US families breastfed exclusively for 6 months, the United States would save $13 billion a year and prevent an excess of 911 deaths, nearly all of whom would be infants

At 80% compliance, $10.5 billion and 741 lives would be saved

Bartick et al, 2010

8 Maryland hospitals have Banned the Bags!

The Johns Hopkins Hospital

Johns Hopkins Bayview Medical Center

Mercy Medical CenterShady Grove Adventist

Hospital

Greater Baltimore Medical Center

St. Mary’s HospitalUpper Chesapeake

Medical CenterMemorial Hospital at

Easton

Based in part on how the above hospitals successfully banned the bags, we have developed strategies to implement

and drive the ban-the-bags campaign in Maryland birthing hospitals

How have Maryland hospitals done it? Consider this:

Ethics: Formula companies are pharmaceutical companies. Are the hospital’s policies for pharmaceutical companies being followed for the infant formula companies?Hospitals are acting as marketing conduits and agents for

infant formula manufacturers

Corporate Compliance: Is the relationship between hospital and formula companies in compliance with the rules all other departments and units must follow?

How have Maryland hospitals done it? Consider this:Risk Management: There are no stock control

measures for distribution of formula gift bags. If there is a recall, the hospital has no way of informing

patients, as lot numbers are not recorded. Hospitals could be liable.

Marketing: Several Maryland hospitals provide new mothers with promotional items such as a bag or car sun visor with the hospital’s logo.

No Maryland hospital that has “banned the bag” has reported significant objections from families.

Proposed hospital strategies: How can your hospital Ban the Bag?

Form an interdisciplinary hospital task forceEducate staff on the effects of free formula sample distribution on

breastfeedingDesign a breastfeeding tool kitReview your hospital policy on marketing productsWork with your marketing department to design hospital gift pack

or other alternative material, if desiredSupport breastfeeding mothers and document breastfeeding trends

at your facilityIncorporate breastfeeding resources into routine prenatal care

packageHighlight discontinuation of commercial formula sample

distribution in your facility’s Best Breastfeeding Practices

Acknowledgements and Resources:

Ruth Namuyinga, MD, MPH Baltimore City WIC Johns Hopkins WIC Baltimore City Health Department Shady Grove Adventist hospital Mercy Hospital Upper Chesapeake Hospital Johns Hopkins Bayview Hospital Memorial Hospital at Easton Ban the Bags National Campaign http://www.banthebags.org Public Citizens Infant Formula Marketing Campaign

http://www.citizen.org/Page.aspx?pid=5392 Maryland Breastfeeding Coalition http://www.mdbfc.org