It’s long been a staple of new motherhood — the diaper discharge bag, a carry-all stuffed with free formula samples that hospitals bequeath to women leaving the hospital. Who doesn’t love free swag?
Breast-feeding advocates, for one. They charge that the bags aren’t as innocuous as they seem, suggesting that the freebies are just an unethical corporate attempt to persuade mothers to choose bottle over breast. Hospitals are listening: a new study published Monday in Pediatrics finds that the number of U.S. hospitals distributing free formula samples is decreasing, although nearly three-quarters still hand them out.
In 2007, just 14% of hospitals refused to give out formula samples. Three years later, researchers checked back in with the 10 states that had distributed the most and least samples and found that the percentage of hospitals declining to distribute freebies had doubled.
“The vast majority are still giving them out,” says Anne Merewood, the study’s senior author and director of The Breastfeeding Center at Boston Medical Center. “But when hospitals see other hospitals discontinuing it, they start to think about it. It’s a tipping point.”
Indeed, researchers noted that the states with a relatively high number of hospitals in 2007 that didn’t participate in giving out formula samples tended to be the ones in 2010 that notched the biggest increases still. Tiny Rhode Island, for example, went from 43% to 86%, with six of seven hospitals declining to hand out free formula; Massachusetts was next in line, jumping from 27% to 64%, or 32 of 50 hospitals. At the opposite end of the spectrum, eight states — including Washington, D.C., New Jersey and Maryland — made what researchers considered no progress: all hospitals in those states continued to give out formula to new moms.
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Typically, formula manufacturers provide hospitals formula for free in exchange for the hospitals giving free formula samples to patients. Perhaps, the trend away from offering freebies may reflect increased scrutiny trained on the health care industry and a subsequent backlash against free samples, whether they be formula or medication. “There’s a general ethical shift away from giving stuff out,” says Merewood, who is also an associate professor of pediatrics at Boston University School of Medicine.
But the concerns transcend ethics. Earlier this year, the U.S. Surgeon General called for more support for breast-feeding, which decreases infants’ respiratory and digestive problems, cuts down on ear infections and is good for mom’s health too. Even formula manufacturers acknowledge that breast milk is better for baby, yet research has shown that free formula given to new moms tends to result in poorer breast-feeding outcomes. The American Academy of Pediatrics, which has called upon hospitals to refrain from distributing free formula, recommends that babies get breast milk exclusively for six months.
“Someone might go home from the hospital determined to breast-feed, but if there’s formula sitting right there, they are more likely to use it,” says Merewood. “If it’s being endorsed by hospitals, people think there can’t be anything wrong with it.”
Women don’t like being duped, says Bettina Forbes, co-founder of Best for Babes, a nonprofit focused on removing obstacles to breast-feeding. “Hospitals shouldn’t be giving out free formula gift bags any more than Weight Watchers should give out doughnuts or cardiologists should hand out bacon cheeseburgers,” she says.
Cheering the slowly growing number of hospitals opposed to formula giveaways is Ban the Bags, a protest movement that emerged in Massachusetts. In 2006, former Mass. Gov. and Republican presidential contender Mitt Romney quashed a move by the state Department of Public Health that would have prohibited the state’s hospitals from giving free formula samples to women. Romney’s decision rankled breast-feeding advocates because it came within days of an announcement from Bristol-Myers Squibb — whose Mead Johnson Nutrition unit makes Enfamil formula — that it was building a pharmaceutical plant in the state.
Breast-feeding supporters suspected a quid pro quo; Romney, for his part, said he felt a ban was just overly intrusive. “We were never able to prove it, but for the life of us, we were never able to understand why Gov. Romney objected so much to banning the bags,” says Melissa Bartick, one of the founders of Ban the Bags and an instructor in medicine at Harvard Medical School. “He has five breast-fed children.”
Outraged, Ban the Bags began taking its mission nationwide, spreading the word online about why free formula is bad for breast-feeding. “There’s a fixed number of births every year, so the only way to sell more formula is to sell less breast-feeding,” says Bartick. “It’s in the interest of the formula industry to undermine breast-feeding.”
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A very few hospitals are going a step beyond banning bags and pursuing “Baby-Friendly USA” designation. Those hospitals not only prohibit formula giveaways but also adopt other initiatives that encourage breast-feeding, such as encouraging “rooming in,” where babies remain with their mothers for easier establishment of early breast-feeding and not giving formula unless it’s medically necessary. (If mothers request formula, however, the hospitals provide it.) As of Aug. 30, just over 100 of about 3,000 maternity centers in the USA have achieved this status.
The small number is hardly surprising, given that an August report from the Centers for Disease Control and Prevention (CDC) found that close to 80% of hospitals give infants formula when it is not medically necessary, which can make the initiation of breast-feeding much trickier. “Hospitals need to better support breast-feeding, as this is one of the most important things a mother can do for her newborn,” CDC director Dr. Thomas Frieden said at the time.
Take a step back, though, and Trish MacEnroe, executive director of Baby-Friendly USA — a project of UNICEF and the World Health Organization — finds the trend positive. Just as the Pediatrics study noted an uptick in the number of hospitals shunning formula hand-outs, Baby-Friendly USA finds itself fielding more inquiries from hospitals about how to qualify; more than 300 hospitals in 48 states have expressed interest.
Predicts MacEnroe, who noted that Michelle Obama, the Surgeon General and the Institute of Medicine have all recently mentioned the initiative: “We’re about to have a growth spurt.”
Bonnie Rochman is a reporter at TIME. Find her on Twitter at @brochman. You can also continue the discussion on TIME‘s Facebook page and on Twitter at @TIME.