Boosting breastfeeding through public policy

By now, the overwhelming benefit of breastfeeding babies to improve their health, and sometimes to save their lives, is universally acknowledged, even by the companies that produce formula.

Breastfeeding: A Sept. 13 Op-Ed article stated that no hospital in Los Angeles had earned the “baby-friendly” label. Providence Holy Cross Medical Center in Mission Hills is so designated. —

But breast-feeding rates remain alarmingly low, and the reason is the relentless marketing of these same companies, the implicit collaboration of well-meaning hospitals and the unwillingness of government to abide by its international commitments.

Though we would all like to believe that we outsmart advertising and make decisions based on rational assessments, formula companies and the World Health Organization know better.


The WHO has long contended that the promotion of breast-milk substitutes negatively affects a mother’s choice to breastfeed.

The detrimental effects of using formula led that agency’s assembly of nations to adopt a code calling for national bans on the promotion of formula, including through the giving away of free samples in hospitals. The U.S. was the only member nation to vote against this code, not accepting it until 1994.

And the U.S. remains virtually the only developed nation that has not enacted a single code provision into federal law.

As infants have no choice about what they consume, they should be offered special protection from a product marketed to their mothers, in line with regulations that restrict the direct marketing of certain foods to young children.


Sadly, in the United States, most hospitals are complicit in promoting formula by offering new mothers a free diaper bag that contains formula samples. This seems mutually beneficial: Everyone loves to give a new mother a present, and most mothers like to receive the bag and the goodies inside. Even breastfeeding mothers are often pleased to have a little formula on hand, “just in case.”

Research from Oregon’s Public Health Division and elsewhere shows, however, that when a breastfeeding mother receives one of these freebies, she is more likely to begin supplementing breast milk with formula and to stop breast-feeding earlier.

Even families that never considered breastfeeding can be duped into spending money needlessly. Families often interpret the hospital-issued samples as a medical endorsement and continue to buy the brand of formula in the bag, rather than a lower-cost generic formula. And yet, all formulas sold in the U.S. must meet the same health, safety and nutritional standards. Buying name-brand formula can cost families hundreds of additional dollars a year. To be sure, some name-brand formulas contain additives unique to their brand, but there is no scientific validation of their benefits. And, as reported in the Washington Post, formula companies have recently lobbied to prevent government-funded testing of their effects.

In order to promote breastfeeding, the United Nations Children’s Fund developed a “baby friendly hospital” designation, incorporating 10 steps hospitals can follow to earn the baby-friendly label. Steps include helping mothers initiate breastfeeding within an hour of birth and giving no supplements to breastfeeding babies unless medically indicated. As part of this effort, hospitals are supposed to refuse all donated formula from manufacturers.

Numerous studies have shown that becoming baby friendly increases breastfeeding rates. At the Boston Medical Center, an inner-city hospital, the percentage of mothers who began breastfeeding shortly after their child’s birth climbed from 58% to 78% in four years, a rate that far surpassed concurrent increases at other area hospitals that did not become baby friendly.

Yet only 96 hospitals and birth centers in the United States have earned the baby-friendly designation; there are none in Los Angeles or Santa Monica. Fortunately, some Los Angeles hospitals have started trying to follow the 10 steps, in part by becoming “gift bag-free.” Similar steps have been successful elsewhere. When all of New York City’s public hospitals went bag-free in 2007, there was no evidence that mothers fled elsewhere to receive gratis diaper bags. Instead, breastfeeding rates at those hospitals skyrocketed.

Formula companies like to frame distributing diaper bags with formula in the hospital as a matter of choice. The International Formula Council set up a website warning mothers about legislative efforts that would limit their right to make a “well-informed decision” and to receive formula samples in the hospital. A sister site offers a petition demanding continued access to formula company materials and samples from hospitals, telling mothers, “Your freedom to choose between breast and bottle feeding could be in jeopardy.”

More hospitals need to evict unnecessary formula samples and their implicit, persuasive and damaging messages. For mothers who need formula, it will remain widely available, and hospitals will always distribute formula to those who choose it.


The federal government should do its part as well by pushing all U.S. hospitals to become baby friendly, by making the WHO code part of U.S. health policy and by encouraging all health insurance plans to cover breast-feeding support and supplies. The government should also fund public service announcements that increase public acceptance of breastfeeding.

In the end, what needs promoting is the interests of mothers and their babies, not the commercial interests of for-profit corporations.

Caitlin Cross-Barnet lectures at Johns Hopkins University and conducts research at its Bloomberg School of Public Health.