Interventions to Reduce Formula Marketing in Medical OfficesFINAL

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For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine

Interventions to Reduce Formula Marketing in Medical Offices Increasing evidence has shown that exposure to formula advertising can negatively impact a

woman’s decision to initiate and continue breastfeeding.1,2,3

A primary component of formula

advertising includes pamphlets, posters, and free formula packs in hospitals and the offices of

pediatricians, obstetricians, and family practitioners. As such, primary care providers may be

inadvertently advertising the use of infant formula and are thereby implicitly discouraging

breastfeeding during the recommended minimum of the first year of life.4 Each primary care visit

before and after birth presents an opportunity to support and encourage breastfeeding.

Interventions to eliminate formula marketing from medical offices are a potentially beneficial

strategy to ensure that these opportunities are not undermined. Though such programs are

limited, certain case studies provide potential model practices and reveal facilitators and barriers

that should be considered in planning future interventions.

Introduction

The American Academy of Pediatrics (AAP) recommends breastfeeding an infant exclusively

for the first 6 months of life, and then introducing complementary foods in conjunction with

breastfeeding for at least the first year of life, continuing for as long as is mutually desired by the

mother and child.5 Breastfeeding is associated with numerous health benefits, including reduced

risk of respiratory infections, asthma, obesity, type 2 diabetes, and sudden infants death

syndrome (SIDS) for the child. For the mother, breastfeeding has been associated with reduced

risk of breast and ovarian cancers, and lower risks of type-2 diabetes and postpartum depression.6

In 2008, New York State (NYS) had a breastfeeding initiation rate of 78%, on par with the

national average, and achieving the Healthy People 2010 goal of a 75% initiation rate.7,8

However, the rate of mothers exclusively breastfeeding in NYS at 3 months is 33% and only

14% of mothers exclusively breastfeeding at 6 months.9 Thus, when looking to increase the rate

of breastfeeding, it is important to consider both initiation and duration.

Although there are many factors determining whether and for how long a woman breastfeeds,

formula advertising can have an impact on these decisions. A large sample intervention study

found that women exposed to formula company produced breastfeeding materials in prenatal

visits to physician offices were as likely to initiate breastfeeding than those who saw non-

commercial breastfeeding materials, but more likely to cease before hospital discharge, and

before 2 weeks post discharge.10 The distribution of free formula has a similar effect. A review

found that women who received formula or formula coupons upon hospital discharge had lower

breastfeeding duration rates than those who received either non-commercial discharge packs or

no packs at all.11

http://www.gao.gov/new.items/d06282.pdf

http://www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/

http://www.cdc.gov/breastfeeding/pdf/2011BreastfeedingReportCard.pdf

http://www.ncbi.nlm.nih.gov/pubmed/10674597

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Throughout their history, infant formula companies have relied on primarily on medical and

health professionals for advertising.12

To date, the majority of interventions in the U.S. have

targeted hospitals. The NYS Department of Health requires hospitals to have written policies to

ensure that breastfeeding infants only receive formula if it is medically indicated.13

In 2011,

Rhode Island became the first state to completely eliminate free formula discharge packs to new

moms. However, there has not yet been a similar level of effort aimed at health professionals

outside of hospitals, in medical offices. Women are recommended to have regular checkups

throughout pregnancy, and then visit the doctor regularly with the child up through their first

year.14

Each of these visits is an opportunity to encourage breastfeeding initiation and support

breastfeeding duration. Eliminating infant formula marketing in medical offices may help ensure

that those opportunities are not subverted. This paper presents guidelines and programs that

support interventions to remove infant formula and related marketing from physicians’ offices as

a strategy to promote the healthful behavior of breastfeeding.

Methods

An initial search for relevant program interventions was conducted using a keyword search for

peer-reviewed literature, grey literature, or program websites. Criteria for relevant interventions

were that a program 1) addressed infant formula, as all or part of the program 2) actively reached

out to medical offices as an intervention (e.g. online toolkits without an outreach component

were not included) and 3) focused on non-hospital based medical offices. This research was

supplemented through phone conversations with representatives of La Leche League, the

American College of Obstetricians and Gynecologists, the N.Y Breastfeeding Coalition and

representatives from each of the three New York State Chapters of the American Academy of

Pediatrics.

It should be noted that while numerous initiatives exist to support breastfeeding mothers,

literature as well as cases of implemented programs specifically on eliminating infant formula

advertising in medical offices is limited. Therefore, three different case studies which met the

above criteria are highlighted. Once case studies were identified, follow up conversations were

held with a program staff from the Loving Support and Tennessee Initiative for Perinatal Quality

Care (TIPQC) interventions to supplement available written materials. No call was conducted

for the Canadian intervention because, due to the academic write up, full implementation and

analysis details were readily available. A further conversation was also held with the author of

the AAP resolution on formula in physicians’ offices and the NYS Special Supplemental

Nutrition Program for Women, Infants and Children (WIC) Breastfeeding Coordinator.

Policy Guidelines

Many major medical institutions have officially recommended eliminating formula marketing,

including free giveaways, from medical offices. Some have also published guidelines on

practices to reduce infant formula advertising specifically for medical offices. These guidelines

could help inform an intervention.

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The World Health Organization’s Ten Steps to Successful Breastfeeding is one guideline that

could potentially inform a programmatic intervention. The document is made for hospitals, as

part of WHO’s Baby Friendly Hospital Initiative (BFHI). A parallel effort to breastfeeding

friendly medical offices, the BFHI designates hospitals to be “Baby-Friendly” when they have

implemented all of the Ten Steps to Successful Breastfeeding, which include provisions for

removing formula.15

The initiative has garnered a great deal of success both across the US and

many developed nations. Numerous studies have shown that babies born in BFHI hospitals are

more likely to have ever been breastfed, and to be breastfed longer.16,17

In recognition of this, the

College of Family Physicians of Canada developed an adaptation of the BFHI 10 steps to apply

to community-based practitioners, known as Breastfeeding Friendly Offices. These are listed in

below.

10 Steps to a Baby-Friendly Office.

From the College of Family Physicians of Canada

1. Support, promote, and protect breastfeeding by informing women

so that they can make an informed decision about breastfeeding.

2. Establish a baby-friendly office policy in collaboration with your

colleagues and office staff, and inform all new staff of this policy.

3. Eliminate the practice of distributing free formula to women from

your office.

4. Ensure that your patient education material and magazines do not

advertise breast-milk substitutes, bottles, or nipples.

5. Display baby-friendly posters that promote breastfeeding.

6. Provide a relatively private area in your office where babies can be

breastfed.

7. Do not refer pregnant women to formula company–run prenatal or

postnatal classes.

8. Eliminate the practice of accepting free samples of breast milk

substitutes or related materials by your office staff.

9. Advocate to ensure that your hospital is a “baby-friendly hospital.”

10. Support continued breastfeeding among mothers who return to

workplaces outside their homes by advocating for baby-friendly

workplaces. Ensure that your office is a baby friendly workplace

for your own staff

Other relevant guidelines include the International Code of Marketing of Breast Milk Substitutes,

also authored by WHO along with UNICEF, and adopted by the World Health Assembly in

1981.18

The code puts forward a series of standards for advertisers, health care systems, and

health workers. Though the code is not legally binding, according to a 2006 review, 72% of all

193 countries have taken some measure to implement the International Code.19

Only 9 countries,

the United States being the only developed nation, have taken no action.20

Among others, the

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code states that ‘no facility of a health care system should be used for the purpose of promoting

infant formula’.21

It also notes that these facilities should not display any formula, promotional

formula materials, and that professional formula representatives should not be permitted to be

used by the health care system.

More recently, the AAP passed a formal resolution that specifically recommended against

pediatricians distributing free formula, coupons, or industry authored handouts. Further, the

Surgeon General’s Call to Action to Support Breastfeeding states that such advertising leaves the

impression that clinicians favor formula feeding over breastfeeding.22

The Academy of

Breastfeeding Medicine’s Protocol to Promote Breastfeeding recommends specific practices to

ensure that a physician’s office eliminates the distribution of free formula and baby items from

formula companies, stores formula supplies out of view, does not display images of infants bottle

feeding, and does not accept gifts, such as writing pads and pens from infant formula

companies.23

Other organizations that have published guidelines or recommendations for

medical offices include the American College of Obstetricians and Gynecologists (ACOG) and

the American Academy of Family Practitioners (AAFP).

Interventions

While programmatic interventions specifically targeting infant formula in non-hospital based

primary care offices are few, particularly in the U.S., some initiatives do provide models. These

vary across a number of factors, such as how they reached out to physicians’ offices, who within

the office was contacted, and the duration of the intervention.

The Loving Support Breastfeeding program, run by the Riverside County Department of Public

Health in California, was one such program. The initiative, funded initially by CA Proposition 10

in 2001, established a 24 hour breastfeeding support hotline for mothers and a physician outreach

program. At the beginning of the program, the physician outreach component involved stocking

medical offices with breastfeeding supportive signs and pamphlets. These materials were

designed to replace formula company generated materials. The program utilized a sub-

contractor, Educational Message Services, to consult on approaching physician staff, including

signing agreements between the Loving Support staff and the physicians’ offices, setting up the

exam room, and follow up contact. The physician outreach strategy was targeted, and begun

narrowly focused with obstetricians’ exam rooms. The exam room displays would be restocked

every two weeks by Loving Support staff.

After initial successes, the program developed “Breastfeeding Representatives”, patterned after

pharmaceutical representatives who are responsible for maintaining relationships with physician

offices. The breastfeeding representatives were responsible for marketing breastfeeding to

offices, including maintaining relationships with the offices, stocking wall displays promoting

breastfeeding and the 24 hour hotline, as well as giving physicians promotional materials such as

clocks, coffee mugs, and note pads with breastfeeding supportive messaging. This enabled the

http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf

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program to spread to over 300 obstetrician and pediatrician offices, which were restocked with

materials quarterly.

The same organization then received a further grant from WIC in 2005 to establish the

“Breastfeeding Friendly Physician Program.” The organization developed 7 steps that must be

achieved, modeled after BFHI, and based on AAP breastfeeding recommendations, among

others, in order to earn the breastfeeding friendly designation. The project was given further

funding after its 5 year grant expired in 2010 and so continues as a WIC pilot program. Currently

regional WIC nutritionists continue to provide WIC and Loving Support materials to offices, as

well as assess for breastfeeding friendly status.

A noticeably different program, which provides a contrasting case study, was conducted by the

TIPQC. The TIPQC Breastfeeding Promotion engaged 6 obstetrician offices in Memphis and

Johnson City, TN. The number was purposefully kept low due to small staff size.24

The program

goal is to promote breastfeeding at prenatal care visits, with the goal of increasing breastfeeding

by the 6 week postpartum visit by 50%. TIPQC developed a toolkit aimed at obstetricians to help

create an overall breastfeeding friendly practice. The toolkit explicitly addressed both removing

formula prompts and replacing these with breastfeeding supportive materials. It also encouraged

providers to develop a written breastfeeding policy and educate staff in its implementation, refer

to community breastfeeding resources, and address TIPQC commonly perceived barriers to

breastfeeding, including convenience, embarrassment, and social support. In addition to free

promotional items and a sample breastfeeding policy, the toolkits included high level evidence

review links for further reading, and a menu of potentially better practices recommended by

health organizations. To date, the program has interviewed 674 women at their 6 week

postpartum visit at the participating clinics.

A third intervention took place in Hamilton-Wentworth, Canada, an area with approximately 200

family medicine offices and 25 pediatrician offices. The interventions utilized the 10 Steps for

Breastfeeding Friendly Offices, a translation of the BFHI ten steps developed by the College of

Family Physicians of Canada, which was implementing the workshops, to measure whether a

one hour luncheon workshop would improve compliance with the 10 steps. Participating offices

were given a self evaluation tool to guide a self assessment on how many of the 10 steps they

complied with prior to the intervention. Then offices attended the workshop, which covered

current rates of breastfeeding in the area, an overview of the 10 steps, and were given sample

breastfeeding polices for offices, support telephone numbers, promotional posters, and a copy of

the International Code of Marketing of Breast-Milk Substitutes. Offices were then asked to fill

out the same self assessment either 6 months after the workshop, or both 6 and 12 months after

the workshop. Importantly, instead of working directly with physicians, the intervention targeted

office staff. The evaluation report notes that the original rationale for this was to reduce study

dropout rate and to increase attendance, however the report stated that there was instead a higher

than expected drop out rate (26%).

The intervention found a significant, but moderate effect of the workshop; the average

compliance of the 10 steps rose from 4.3 to 5.6. The greatest difference was seen 6 months after

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the workshop, with a subsequent decline to an average 5.1 for the group measured at 12 months.

The greatest improvement was in displaying non-industry breastfeeding promotional materials,

however it should be noted that at baseline 87% of the already offices did not distribute free

infant formula.

Key Implementation Considerations

While few of these case studies specifically measured reduction of formula advertising exposure,

the research for this paper brought forward key factors to consider in implementing an

intervention.

Arguments to improve physician awareness should be evidence based - All three

interventions introduced arguments using a heavily evidence based approach. It was found that

while pediatricians and obstetricians generally accepted that breastfeeding is preferable, there

was the pervasive belief that distributing formula packs was formula was a ‘nice gift’ and not

detrimental to breastfeeding.25,26

Thus a facilitator to specifically reduce infant formula presence

may include a focus on current evidence of the effect of formula marketing on breastfeeding

rates. The TIPQC intervention additionally provided surrounding evidence, including

breastfeeding rates in the county and the evidence base for recommended changes in office

policies. It was noted that including recommendations made by medical organizations that the

physician was a part of (e.g. AAP, AAFP, or ACOG) was also advantageous.27

Physicians may be concerned about providing support in lieu of formula- Formula

companies frequently market their product not as a substitute for breastfeeding, but rather as a

supplement should there be any problems.28

Physicians may be hesitant to eliminate formula

because they do not feel they can provide appropriate breastfeeding support. One of the foremost

barriers noted across interventions was that physicians did not feel that they knew appropriate

lactation experts within their community to refer their patients to. Both the TIPQC and Canadian

interventions attempted to address this by providing sample referral lists. However filling and

maintaining such a list might be a significant burden.29

This issue is heightened by the current

perception among physicians that they do not have adequate training to discuss and provide

follow up support for breastfeeding; a number of sources have noted a lack of breastfeeding

support in physician training and residency curricula.30,31

Ensuring that physicians feel

comfortable that support can be easily provided for breastfeeding mothers may be important for

increasing physicians’ comfort with removing formula as an option from offices.

There is a difference between refusing samples and removing giveaways- While the

Canadian group’s adaptation of the 10 steps specifically states that offices should not accept free

formula samples, the Loving Support program steps simply say that formula should not be given

away. This is an important distinction to consider. Ending free formula giveaways and removing

formula from sight reduces formula exposure for those who visit the office. However, it was

noted that physicians may still want to keep formula in stock in case it is requested of them, and

may be disinclined to pay for formula they would otherwise receive for free. 32

On the other

hand, continuing to accept free samples continues the relationship between medical offices and

formula industry representatives. It was noted that this relationship could also be framed as a

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medical ethics issue, similar to offices accepting samples from pharmaceutical companies. Either

simply eliminating free giveaways or asking an office to refuse free samples could effectively

reduce formula marketing to the end target, the patient. This should be a key consideration of any

intervention, and programs should be explicit what steps they are asking medical offices take in

this regard.

Maintaining a relationship furthers programs-The Loving Support intervention attributes its

success to the fact that a great deal of effort was put into maintaining long term relationships

with offices.33

This included having dedicated staff members (the breastfeeding representatives),

keeping those staff constant, hiring a consultant to provide expert advice in maintaining this

relationship, and , over time developing a positive rapport between staff and the whole office.

While this is certainly a more labor intensive approach, it has the added benefit of continuing to

support the offices in supporting breastfeeding. Alternatively, the short term Canadian

intervention found a decline in compliance without maintaining any kind of relationship.34

Indeed, the Canadian study notes that “influencing physicians to make their offices baby-friendly

might require more intensive intervention strategies.”

Engaging the right staff at the right time is important- The Canadian evaluation noted that

while engaging support staff was initially thought to reduce dropout rate, the study in fact

experienced a higher than expected drop out rate. Thus in leveraging an organized outreach, who

exactly within the office is being engaged for change, and when in the process, is important.

TIPQC notes the advantage of identifying a ‘breastfeeding champion’ within the practice to

maintain the cause.35

It was further noted that within group practices, it was important to engage

the senior partner(s) in addition to any breastfeeding champions that might exist. Thus at a

minimum there appears to be value in directly involving the physician. Another effective

champion to leverage for specifically obstetricians may be hospitals that have eliminated formula

giveaways.36

TIPQC noted that in the future they were hoping to link their prenatal intervention

program with their hospital intervention program.37

The Loving Support program engaged both physicians and office staff. 38

There may be a

particular advantage to engaging both. Even once a physician has signed on, lack of

communication with office staff, including part time and rotating staff, can hurt compliance.39

Physicians may not be putting out many of the promotion materials, such as pamphlets,

themselves, and so ensuring that staff are aware of new policies is important.

Medical offices are increasingly busy- The TIPQC intervention noted the increasing

constraints on physicians and lack of time as an additional barrier. General practitioners and

pediatricians are expected to pay attention to a rising number of issues and behaviors. Thus

physicians’ resistance simply due to lack of time may become a barrier to an intervention.40

Similar may be true of over tasked office staff. Ensuring that interventions are sensitive to the

time and pre-existing constraints of medical offices is important when considering programmatic

interventions.

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Name Overall

Intervention

Target Formula Related

Activities

Outcomes

Loving Support

Program

Designated staff as

“Breastfeeding

Representatives”

who were

responsible for

maintaining

relationships with

offices and

‘marketing’ the idea

of Breastfeeding

Developed criteria

for “Baby Friendly

Physicians”, and

designated offices

that met the criteria

as Baby Friendly

Obstetricians

and

Pediatricians

Breastfeeding

Representatives

replaced infant

formula company

produced advertising

with breastfeeding

friendly pamphlets.

One of the seven for

Baby Friendly

Physicians included

removing all formula

related or sponsored

advertising

Breastfeeding

representatives provided

materials to over 300

pediatrician and

obstetrician offices.

Number of offices which

have received “baby

friendly’ designation not

available.

TIPQC

Breastfeeding

Promotion

Project- Prenatal

Care

Reached out to work

with 6 obstetricians

offices. Developed a

toolkit to assist

Obstetricians Toolkit explicitly

addressed both

removing formula

prompts and replacing

these with

breastfeeding

supportive materials

The project continues to

work with the 6 offices. As

part of a planned

evaluation, 647 women

have been interviewed at 6

weeks postpartum.

Program expansion is

planned.

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The College of

Family Physicians

of Canada-

Breastfeeding

Friendly Office

Initiative

Workshop

Held a 1 hour

workshop targeted at

office staff to

improve

implementation of

the 10 Steps for

Breastfeeding

Friendly Offices

Family

Practitioners

and

Pediatricians

Four of the ten steps

related to infant

formula, including no

longer accepting free

formula samples, no

longer distributing

free formula samples,

ensuring educational

materials and

magazines did not

contain formula

promotion, and not

referring women to

formula company

sponsored classes.

The workshop had a

moderate but statistically

significant effect on

improving implementation

of the 10 steps, from an

average of 4.3 to 5.6

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Impact

The U.S. Preventative Services Task Force’s evaluation rated interventions in primary care to

promote breastfeeding on the whole a “B”, indicating that the underlying evidence was strong,

and that the benefit was expected to be moderate. However, this was broadly on all primary care

interventions; primary care interventions specifically targeted at removing formula from offices

may be more or less likely of success.

A survey of obstetrician offices in Monroe, NY found that 61% of offices offered free formula,

and 41% displayed formula promotion. In a survey at a hospital in Rochester, NY, 65% stated

that they had received free formula offers during their pregnancy.41

If these rates hold true for

New York State, a program to encourage limiting these promotions could potentially be

impactful.

One impact which was not covered in the models reviewed is disparities in breast feeding.

While 75% is the average initiation rate, Hispanic and Latino, high income, and mothers older

than 30 years all had initiation rates over 80%.42

On the other hand, non-Hispanic black mothers

have an initiation rate of 58.1%, while 67.5% of low income mothers initiate breastfeeding, and

59.7% of mothers under the age of 20 initiate breastfeeding. 43

The impact of reducing formula

marketing in physician offices on WIC populations is difficult to assess. Though breastfeeding

promotion is an explicit piece of WICs work, WIC purchases more than half of all infant formula

consumed in the USA.44

Whether removing infant formula advertising from physicians’ offices

will have a greater or lesser impact on a population which is exposed to a secondary major

source of formula advertising is difficult to assess. Any intervention in reducing formula

marketing ought to pay attention in particular to disparities in breastfeeding rates. Encouragingly,

while physician encouragement of breastfeeding has been linked to a fourfold increase in

breastfeeding initiation, the same study found it increased by nearly fivefold among black

women; and by nearly 11-fold among single women. 45

Pairing an effort to reduce marketing

with additional support to physicians’ practices to actively encourage breastfeeding may

therefore be important.

Conclusion

Programmatic interventions to reduce infant formula marketing in medical offices are limited in

the United States. However certain key examples, policy guidelines, and key informants can

provide information of different kinds of interventions. Key considerations that emerged

included maintaining a strong and lasting relationship with participating medical offices, having

an organized outreach strategy and being conscious of who within the office is being engaged,

couching the approach to physicians in the strong evidence base for the interventions, addressing

a lack of knowledge around breastfeeding support amongst practitioners, considering the

distinction between refusing free samples and eliminating free giveaways, and appreciating the

lack of time to dedicate to the cause in an increasingly busy practice. Additionally it was noted

that numerous published guidelines exist which can help guide an intervention, such as the

WHO’s Ten Steps to Successful Breastfeeding, which served as the bases for both the Loving

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Support and Canadian intervention guidelines, and the International Code of Marketing of Breast

Milk Substitutes, which has been successfully adopted to varying degrees in a number of

different countries. Evidence shows that formula marketing has the ability to impact a woman’s

decision to breastfeed, and numerous health organizations across the U.S. and internationally

have stated that medical offices should not be used to advertise infant formula. As such,

programs aiming to stem infant formula marketing in medical offices are an evidence based and

supported strategy, though further evaluation is needed on its potential reach and impact.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082991/


















http://www.californiabreastfeeding.org/Breastfeeding_Friendly_MD_Offices__1230_Jan_24_Susanna.pdf





















http://www.bcbabyfriendly.ca/workshop%20baby%20friendly%20office.pdf
































































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Interventions to Reduce Formula Marketing in Medical OfficesFINAL