Friday, June 27, 2014

Why I am (surprisingly) in favor of banning the bags

Increasing numbers of American hospitals seem to be "banning the bags" these days--that is, abolishing their long-established habit of handing out free samples of formula to mothers on maternity wards. The "Ban the Bags" campaign has engendered a lot of debate, with most breastfeeding advocates strongly in favor, and many formula feeding advocates skeptical or somewhat offended. Not surprising, really: "Ban the Bags" very often comes hand-in-hand with measures which have upset many formula feeders, such as harassing or pressuring mothers who choose to bottle-feed. The Baby Friendly Hospital Initiative (BFHI) has been a case in point here. I have "issues" with several bits of the BFHI, as I'll be discussing in a future post. However--perhaps somewhat surprisingly--I'm still inclined to be in support of banning the bags. Here's why.

Paying for the label
The formula samples American families receive in hospitals and doctors' waiting rooms are invariably branded formulas, such as Gerber, Enfamil and Similac. You can buy these at the store, too, but big stores also sell "generics" (store brands) such as Walmart's Parent's Choice. British readers probably won't be familiar with generic formulas, but basically it's like when you're in Superdrug and you could buy either Calpol or Superdrug's own paracetamol suspension. It's just as good a product, but has a less prestigious label (and price tag) on it.

Generic vs brand formula is basically the same deal. All formulas in the States are required to meet strict, identical standards in terms of ingredients, processing requirements and so on. If you have a moment, go to the first link in the "Further reading" section below, and check out the lists of ingredients in generic formulas versus the fancy-pants ones: you'll find that each generic formula is basically identical to its brand equivalent. The various companies are also required to follow identical rules as to the quality and sourcing of each ingredient.

This is not to say, incidentally, that "all formulas are exactly the same"--they're not. There's cow's milk, goat's milk, soy, elemental, there are different levels of iron, there are different whey to casein ratios, there are things like DHA and probiotics which may or may not be added--but the thing is, whatever permutation you are looking for--say, "I want a soy-based formula with added DHA"--you can almost certainly find that option in either a brand or a generic form, and they're both equally good (I think there are fewer organic generic options, but some have appeared in recent years). There is no particular reason to purchase a brand formula unless you actually have found that your child does poorly on the generic option and seems to be better suited to the brand one when you try it out. Otherwise, it's as pure an example of "paying for the label" as you're likely to find. And the price differences are substantial; added up, we're talking anywhere between UD$400 and UD$700 a year. Double that if you have twins. This can be particularly hard on parents who fall into that unsweet spot of being poor yet not quite poor enough to qualify for income support programs or free formula supplies. Worryingly, parents who struggle to pay for formula sometimes try to "stretch" it through over-dilution or feeding leftovers from the last feed.

Where your money goes if you buy a brand formula
even though your baby does fine on generic.
 Yes, this is my kitchen. No, it isn't normally as clean as this. 

Can I trust my doctor?
The other casualty here is the credibility of healthcare professionals. Most of us think of doctors as authority figures, so when someone at a hospital or pediatrician's office gives you something, they are--whether this is intended or not--effectively endorsing the product with an unspoken message of "I, as a medical professional, believe that this product is the best thing for you, based on scientific evidence." When that kind of endorsement is being applied to a product whose high price tag is not justified by any superiority of quality, as a result of what is basically a commercial marketing tie-up with a corporation.... well, I find that tacky and also borderline unethical. And yes, I know this is far from the only case of this kind of thing happening--doctors also recommend brand-name drugs over generic versions to patients all the time (and I don't think they should do that either). But doing this stuff to new parents seems like a particularly low trick, given how vulnerable new parents are to marketing that appeals to fear.

Fear is probably the strongest emotion that most of us feel as we take our tiny, precious newborns home with us--that, and a desperate desire to do absolutely anything that might, possibly, help to keep them safe, whatever the cost. (This post comes to you from the woman who gave her baby her first bath at home in bottled water because I was convinced that radiation in the tapwater was going to give her cancer.... or something. Yes, really.) Doubly so for women who really wanted to breastfeed and are now writhing with guilt. Plus, once you have finally succeeded in getting your newborn to feed normally, poo normally and sleep at least fitfully on Brand A formula, you really, really, really don't want to start switching to Brand B. For all these reasons, parents who have been started on Enfamil or what-have-you at the hospital are highly likely to keep on using it.

When people shun vaccines and other conventional medicine recommended by the medical profession, one reason invariably cited for doing this is "You can't trust doctors, because they are shilling for pharmaceutical companies." The idea that the standard vaccine schedule is based on doctors' desire to get free mugs and ballpoint pens from Pfizer and AstraZeneca is bizarre, but when the medical profession falls into the habit of endorsing products based on a commercial rather than scientific rationale, it just doesn't look great. With so many voices out there encouraging parents to mistrust and shun conventional medicine, it's really important that doctors and other healthcare professionals ensure that all their recommendations are ethical and evidence-based.

And it also doesn't help that a high percentage of pediatricians and doctors are also actually recommending branded formulas to families and steering them away from generics--based on precisely zero evidence--which makes me wonder whether the presence of all those attractively packaged samples and freebies is also having a kind of subtle subliminal effect on medical workers' thinking too. Doctors are only human, after all. It's often said (with some truth) that "doctors and pediatricians tend to be clueless about breastfeeding" but looking at articles like this one (check out the comments on generic formula by the vice-chair of Pediatrics who is quoted) makes me feel that some of them could do with a bit more education about bottle-feeding as well.

Formula = Breast pads
Perhaps one's feelings about "Ban the Bags" will depend on where one is coming from (literally). If you are American and have grown up with the idea of formula bag freebies, not having samples is likely to feel like having something taken away and also like an attack on one's choices. For people (like me) from the UK or Australia, where infant formula samples aren't handed out anyway, there is a sort of vague feeling of "Huh? Why would one expect freebies in the first place? This is just being neutral. Nobody's stopping you from buying your own formula if you want it." Nobody should ever be harassed for feeding choices, but I don't think "not giving a freebie" amounts to harassing women for formula feeding any more than my hospital's failure to provide me with free breast pads, nipple cream and nursing aprons could be considered disrespecting my choice to breastfeed. 

How about just handling formula in hospitals in the same kind of way we handle other maternity-related supplies, like breast pads? What that would mean in practice will depend, ultimately, on how your hospital/healthcare system/insurance coverage works. If a hospital is in the habit of providing products like breast pads, diapers and sanitary protection for free, there's no reason it can't provide formula as well--but it should be providing generic formulas that meet the requirements of food regulation authorities, not overpriced brand versions, and not as part of marketing or commercial tie-ups. If, on the other hand, a hospital expects mothers to provide their own sanitary protection, breast pads and so on (as did my hospital), it's perfectly reasonable to expect them to bring their own formula to the hospital as well, if they choose to formula feed. If a woman runs out of formula or if a breastfeeding mother needs formula or changes her mind, the hospital can provide her with generics, and add the cost to her hospital bill at the end--just like if you ran out of nipple creams or diapers. And yes, hospitals should be supplying low-priced generic breast pads and diapers too, as long as these do the job as well as the fancy brands.

By the way, there is definitely nothing wrong with formula companies posting free samples of Similac or whatever to families who email them with a request, but this should be based on an informed decision. It would be good if prenatal infant feeding education gave clear, science-based information on formula, including discussing the fact that generic formulas are not inferior to the brand versions. 

In summary, while there are reasons to be concerned about certain aspects of the BFHI, there is also a sound rationale for getting rid of the practice of having medical institutions pushing marked-up brand formulas at parents without any scientific basis for the inflated cost. Instead of handling formula like either an illicit substance or a money-spinner for companies, let's handle it like what it is--a babycare product--and in a manner that's neutral and science-based. Doing so will not only result in better support for both breastfeeding and formula feeding families, but can also help ensure that the medical profession maintains the respect and trust of parents.

Further reading
Supplement to Consultant for Pediatricians (February 2014): A Comprehensive Overview of Store Brand Infant Formula/Guiding Parents in Formula Selection: How Do Store Brands Compare to National Brands?  This easy-to-read supplement is worth a look. It also has a big, colorful table where you can look at the ingredient comparison for yourself.


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