For years, virtually every new mother has been sent home from the hospital with a gift bag full of free product samples, including infant formula.
Now health authorities and breast-feeding advocates are leading a nationwide effort to ban formula samples, which often come in stylish bags with formula company logos. Health experts say they can sway women away from breast-feeding.
As of 2011, nearly half of about 2,600 hospitals in a survey by the Centers for Disease Control and Prevention had stopped giving formula samples to breast-feeding mothers, up from a quarter in 2007. The survey did not ask about distributing samples to non-nursing mothers.
Recently, 24 hospitals in Oklahoma agreed to a ban, and Massachusetts became the second state, after Rhode Island, in which all hospitals halted free samples. In New York City, Mayor Michael R. Bloomberg started the "Latch On NYC" campaign, urging hospitals to stop giveaways and monitor formula like other medical supplies, stored in locked cabinets and accounted for when mothers have medical needs or request it; 28 of 40 hospitals have agreed.
The debate over formula samples isn't about whether breast-feeding is healthier. Even formula companies acknowledge that "breast milk is the gold standard; it's the best for babies," said Christopher Perille, a spokesman for Mead Johnson, which makes Enfamil formula.
Breast-feeding decreases babies' risk of ear infections, diarrhea, asthma and other diseases, and may reduce risk of obesity and slightly improve I.Q., experts say. The question is whether samples tempt mothers who could breast-feed exclusively for the recommended six months to use formula when they're exhausted or discouraged if nursing proves difficult. The C.D.C., the World Health Organization and breast-feeding advocates say samples turn hospitals into formula sales agents and imply that hospitals think formula is as healthy as breast-feeding. Health experts warn that even small amounts of formula dilute breast-feeding's benefits by altering intestinal micro-organisms and decreasing breast milk supply, since women produce less when babies nurse less. They say that while some women face serious breast-feeding challenges, more could nurse longer with greater support, and that formula samples can weaken that support system.
"We're not anti-formula," said Dr. Melissa Bartick, a founder of Ban the Bags, a breast-feeding advocacy group, which reports that one-fifth of the country's nearly 3,300 birthing programs have taken more comprehensive steps of banning samples and logo-emblazoned bags for all mothers. "If a woman makes an informed choice to formula-feed, the hospital should provide that formula. But hospitals shouldn't be marketing it."
The industry and some mothers say samples provide a healthy alternative and offer relief if nursing causes pain, fatigue or frustration. They disagree that samples can shake the resolve to breast-feed exclusively.
"Babies grow fine on it," said Mardi Mountford, executive vice president of the International Formula Council, who breast-fed her baby exclusively. "And moms tell us they like getting the samples."
Ann Roberts, 32, a book buyer in Atlanta, said she had wanted to breast-feed exclusively, but found it painful and her daughter was underweight. The sample "gave me peace of mind," she said. "It would have added stress to have to send my husband to the grocery store to buy formula." She continued supplementing with formula, and like many women who formula-feed, bought the brand the hospital gave out. "We are using that brand because we got the sample," she said.
Do samples sway women to use formula in the first place? Some studies have found that women who receive samples do not breast-feed as long as those who don't; others found no significant connection. People on either side of the sample issue agree that hospitals should support breast-feeding in many ways.
The campaign to ban samples stirs strong feelings among mothers, including those who are health care providers.
Megan Caron, 27, a nurse in Massachusetts, felt a sample coaxed her to capitulate when breast-feeding her daughter became challenging. "If it wasn't there, I think I would have tried a little bit more to get breast-feeding down," she said. "And once they get formula, it's hard to get them back."
Dr. Rachel Freedman, 34, an oncologist, had a different experience after giving birth this year at her hospital, Brigham and Women's in Boston. It long ago banned formula samples. But Dr. Freedman, who said she intended to breast-feed but had difficulty, concluded that samples could be "nice when you're a mother and you get into a pinch in the middle of the night and you're exhausted." When her milk did not come in, nurses encouraged her not to give up. But after hours of trying, "we broke down" and gave formula, she said. Her milk came in two weeks later, but not enough to nurse exclusively. "Maybe I wasn't patient enough, but at the time I thought he was starving," Dr. Freedman said of her son.
Dr. Nicole Leopardi, 30, a pediatrician, said the sample she got after giving birth at Virtua Hospital in Voorhees, N.J., in 2006, helped influence her to supplement with formula when she became worried she wasn't producing enough milk. "Since it was available, I think I probably kept doing it those early days," she said. "I was under the misconception that that would help the baby be more satisfied." This year, Dr. Leopardi gave birth at Cooper University Hospital in Camden, where she is affiliated. Cooper recently banned formula samples, and she said its unequivocal breast-feeding support helped her keep nursing.
At Cooper, where 70 percent of mothers were formula-feeding, the ban improved breast-feeding rates significantly. In a study, Dr. Lori Winter, a pediatrics professor at the University of Medicine and Dentistry of New Jersey, introduced hospital bags without formula logos or samples. At first, she was stunned to find that mothers were receiving formula samples anyway. Nurses were slipping them in, she said, because "they didn't believe these babies weren't going to starve. Cooper began storing formula in locked cabinets and having nurses document when mothers had medical needs or requested it. Now, 70 percent breast-feed in the hospital.
Other hospitals say they do not believe samples discourage breast-feeding. At Virtua, which runs two maternity hospitals in suburban New Jersey, Dr. Alka Kohli, vice president of medical affairs, said officials would re-evaluate formula giveaways. But she said that because of Virtua's breast-feeding programs, "despite the fact that formula sits around, our breast-feeding rates climb every year."
"Ban the Bags" campaigns have seeped into politics. Mayor Bloomberg's critics call "Latch On NYC" another nanny-state initiative. Breast-feeding advocates are criticizing Mitt Romney's 2006 decisions as Massachusetts governor to pressure the state's Public Health Council to reverse a ban on formula giveaways, and replace three council members who objected.
When UMass Memorial Medical Center in Worcester eliminated samples in 2005, people complained, said Dr. Ellen Delpapa, chief of maternal-fetal medicine. UMass partly retrenched, giving coupons for free formula to women not exclusively breast-feeding. Only when more Massachusetts hospitals stopped samples did UMass reimpose its ban.
Some hospitals say manufacturers make banning giveaways harder. Dr. Winter called it "a big production to disengage companies from flooding us with these bags," adding, "I was reported to the chief of neonatology because the companies said I refused to meet with them."
At Beverly Hospital, the last Massachusetts hospital to ban samples, companies "were very infiltrated," said Rebecca Gadon, director of maternal, newborn and cancer care. She arrived in 2008 to find formula companies giving the staff gifts and paying for continuing education classes.
Hospitals often also receive all formula supplies free from manufacturers, providing incentives to cooperate. Many hospitals continue to accept supplies after banning samples, although the C.D.C. and other agencies discourage this. UMass Memorial still accepts Similac and Enfamil, and while it is considering buying formula, "when they tell us how much we're getting for free, that's worth a lot," Dr. Delpapa said.
The chief of the C.D.C.'s nutrition branch, Laurence Grummer-Strawn, said he was concerned enough that he had "spoken to people at formula companies suggesting they change their marketing practices."
He also tells hospitals to buy formula, with competitive bidding like for other supplies. "We shouldn't be receiving free giveaways from pharmaceutical companies, we shouldn't be receiving free giveaways from formula companies," Dr. Grummer-Strawn said.
Neither the Formula Council nor Mead Johnson would discuss marketing specifically. Abbott Nutrition, which makes Similac, deferred questions to the Formula Council. Mr. Perille of Mead Johnson said factors like birthrate and efficiency were more important to business success than sending samples to hospitals or pediatricians' offices.
Still, hospitals are "the ideal setting for new mothers to get information about feeding options," Mr. Perille said. And "if they're going to formula-feed, we would like them to choose our brand."