interventions to reduce formula marketing in medical officesfinal
TRANSCRIPT
1
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
2
For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine
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.
3
For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine
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
4
For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine
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
5
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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
6
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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
7
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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.
8
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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.
9
For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine
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
10
For more information, contact Elyse Powell ([email protected]) at The New York Academy of Medicine
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
11
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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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