1. A Case for Hospitals: An Evidence-Based Approach Maryland Breastfeeding Coalition http://www.mdbfc.org Ban-The-Bags Maryland!

2. National Ban-the-Bags Initiative…What’s involved? The hospital staff does not provide formula company give-away (diaper) bags, coupons, sample formula  Includes breastfeeding mothers and babies  Includes 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

4. When Health Care Providers hand out formula, they implicitly endorse formula, including the particular brand that is distributed

5. 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.

6. 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”

7. 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.

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

9. 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 oP=0.004 Frank et al, 1987

10. 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% respectivel y Frank et al, 1987

11. 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

12. Decreased continuation of breastfeeding WIC 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

13. 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

14. 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% respectively P=0.01 Wright et al, 1996

15. Current Recommendations: American Academy of Pediatrics:  Exclusive breastfeeding for the first six months  Breastfeeding with complementary foods to 12 months  Continuation 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.

16. Current Recommendations CDC 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 Commission Exclusive breast milk feeding in the hospital is now one of their Perinatal Care core measures.

17. Why the Fuss? Besides never being recalled, Breast milk has many benefits…

18. Just a few of the benefits from breastfeeding Health 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, 2007 Bai, 2009

19. 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

20. 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

21. 8 Maryland hospitals have Banned the Bags! The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Mercy Medical Center Shady Grove Adventist Hospital Greater Baltimore Medical Center St. Mary’s Hospital Upper Chesapeake Medical Center Memorial 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

22. 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?

23. 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.

24. Proposed hospital strategies: How can your hospital Ban the Bag? Form an interdisciplinary hospital task force Educate staff on the effects of free formula sample distribution on breastfeeding Design a breastfeeding tool kit Review your hospital policy on marketing products Work with your marketing department to design hospital gift pack or other alternative material, if desired Support breastfeeding mothers and document breastfeeding trends at your facility Incorporate breastfeeding resources into routine prenatal care package Highlight discontinuation of commercial formula sample distribution in your facility’s Best Breastfeeding Practices

25. 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.orghttp://www.banthebags.org Public Citizens Infant Formula Marketing Campaign http://www.citizen.org/Page.aspx?pid=5392 http://www.citizen.org/Page.aspx?pid=5392 Maryland Breastfeeding Coalition http://www.mdbfc.orghttp://www.mdbfc.org