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.

Why we need "feeding rooms," not "breastfeeding rooms"

It's a funny thing about Japanese breastfeeding; breastfeeding rates here are high, yet you will rarely see a woman actually nursing. I remember pondering this question in pre-motherhood days and being very puzzled by it. Later on, however, I understood how things worked after I was initiated into the mysteries of the popular Japanese institution of the junyuushitsu (“breastfeeding room”).

These rooms, commonly found in stations, department stores, shopping centers and other facilities, vary considerably; some are little more than a small cubicle with a couple of chairs, while others are quite spacious rooms equipped with sofas and equipment ranging from vending machines to taps emitting water heated to 70 degrees C (accompanied by a little sign assuring users that the water in question was bottled and filtered—my brief period of nursing-room use was shortly after the TEPCO nuclear meltdown in Fukushima, following which parents were warned not to use tapwater in babies’ bottles after briefly elevated levels of radioactivity were reported). As this implies, the larger junyuushitsu are often used by bottle-feeding parents as well; breastfeeding mothers using these rooms have the option of disappearing into a curtained-off cubicle if they aren't happy about being visible to any dads who might be on the couch giving a bottle.

I made sparing use of these rooms back when Little Seal was a baby, mostly in the newborn days when I was nervous about breastfeeding her in public; even after I had gained more confidence, there were times when there was something to be said for making an all-in-one stop (feed + diaper change) without having to shell out US$6.00 on a cup of coffee. That said, I usually fed wherever I happened to be, albeit with a nursing cover.

Why breastfeeding rooms are controversial
Breastfeeding rooms have been cropping up all over the place in the Western world too, and are an increasingly common sight in shopping malls and transportation hubs. One Vermont company is even using crowdsourcing to build free-standing "lactation stations":  "Mothers deserve a clean, comfortable, private place to pump and nurse – not a bathroom." While on the face of it, such rooms appear to be a supportive measure for breastfeeding, they’ve always been accompanied by controversy.

"They seem to prefer the idea of hiving off bf mothers into corners so they're invisible to the rest of the population....." "The potential problem with this is that, once these areas are set up, members of the public and/or service station staff might start trying to send all bf-ers to these areas - 'Excuse me, didn't you know there's a private area for that?' - and before you know it we'll be segregated into some dank area that smells of soiled nappies, and where the dirty crockery is never removed," grumbled commenters on one discussion regarding a government proposal to establish nursing rooms at motorway stations in the UK. The commenters are expressing a commonly-held view that breastfeeding rooms actually discourage breastfeeding by sending out unwelcome messages--that breastfeeding is inherently shameful and should be hidden away, that it can only be done in special places and that women who are out and about should be required to spend their time hunting for nursing rooms—and by giving ammunition to those who harass women for nursing in public.

I don’t think these are idle concerns at all. I have seen numerous discussions in which a woman’s right to breastfeed her baby in a café or restaurant was shot down on the grounds of “There are mothers’ rooms where you can do that kind of thing. Why can't you just feed in there?” Here's the thing, though: if I am having lunch or a coffee, I’d prefer to feed my baby where I am, thank you, rather than leave my friends and drag myself off to some separate area, as though I were committing some disgusting act, while my meal gets cold. And trying to get your errands done with a baby (who may feed as often as every 1.5-2 hours in the newborn period) is tough enough without having to plan the whole outing around the availability of nursing rooms. Or drag yourself, stroller and shopping up and down the corridors of some God-forsaken shopping center or railway station trying desperately to find the nursing room, while your hungry infant wails and everyone glares at you.

And yet… I don’t think nursing rooms can simply be written off as A Bad Thing, either. Some women are always going to be too shy to feed in locations where others can see them—especially in the newborn days when trying to latch can feel like assembling a particularly fiddly piece of flatpack furniture. Some babies go through distractible phases and try to rubberneck everything in sight, which can make feeding a nightmare. Sometimes the need for a feed strikes when you not in a café but in the middle of the supermarket or something—even the most chirpy lactivist might feel more comfy feeding on a chair rather than sitting herself on the floor next to the fruit and veg. We also have more mothers who pump exclusively nowadays; I completely support mothers' right to pump in public, but I think we need to be realistic about the fact that very few women are actually comfortable doing this. Trying to find clean and private places to pump on-the-go can be a nightmare for EPing mothers, who often resort to toilet cubicles. In short: I like the existence of breastfeeding rooms. But I don’t want mothers to be chased into them.

What about bottle feeders?
At first glance, providing special spaces for people to bottle feed (like the British department store John Lewis does) sounds a bit odd. But formula feeders may also find themselves sometimes dealing with distractible babies or having to give a bottle in an environment where there is nowhere to sit down. Whatever the reason, formula feeders surely also deserve the option of a quiet space where they don’t have to purchase a cup of tea. Unfortunately, this raises some tricky issues. Formula feeding, unlike breastfeeding, can be done by both men and women. Nobody wants to discriminate against fathers (God knows, the lack of changing tables in most mens' toilets is annoying enough); and yet the fact remains that many breastfeeding mothers use breastfeeding rooms precisely because they don't feel comfortable nursing when there are men around.

A modest proposal

Suggestion: Dump the idea of “breastfeeding rooms” and instead shift towards the concept of “feeding rooms" or "parent and baby rooms" where all parents are welcome, along the lines of the larger junyuushitsu I see in Japan and the generalized "baby rooms" which are sometimes found in the United States and Britain. And—this is important—the sign on the door should contain a message along the following lines:

Parent and Baby Room

Parents are welcome to breastfeed/bottle feed babies anywhere in our facilities; this room provides a quiet space for those who prefer privacy.

What feeding rooms need to have:

• “Essential”

- Chairs where both breastfeeders and bottle feeders can sit in comfort and feed their babies

- Small curtained-off booth/area with a chair, exclusively for breastfeeding/expressing mothers who prefer privacy

- Table (where bottles can be mixed and prepped)

- Handwashing facilities

- Electrical outlet (for electric breastpumps)

• Not essential, but “nice to have”

- Tap dispensing hot water heated to 70 degrees C

- Vending machine with drinks, snacks and baby supplies—baby wipes, ready-to-feed (RTF) formula cartons, disposable diapers and hand sanitizer

- Magazines, pleasant décor and a bit of general nice ambience

I really feel that establishing rooms along these lines--rather than "breastfeeding rooms"-- could solve several problems simultaneously. They would, obviously, provide a quiet space for breastfeeding, pumping and formula feeding parents. By shifting the emphasis towards “supporting all parents/providing a relaxing space” rather than “hiding breastfeeding,” they could resolve the awkward questions that are raised about breastfeeding and women’s right to do it in public. And a clear, visible statement affirming women’s right to nurse anywhere in the shopping mall/station/airport etc. would help ensure that the existence of feeding rooms does not become a tool for harassing nursing mothers; anyone who walks past the door and sees the sign will get a bit of education on mothers’ nursing rights, rather than simply registering the existence of the room and interpreting this to mean that mothers are “not supposed” to breastfeed anywhere else. Finally, the provision of a curtained-off space within the room would mean that shy mothers and exclusive pumpers get the privacy they need. 

A couple more things: Whoever is in charge of designing baby rooms… please, please consider separating the baby changing facilities from the feeding areas. If they really have to be in the same room, for God’s sake make sure the bin is regularly emptied and the room is a decent size and well ventilated. No parent should have to feed their child in a stinking room next to a (usually overflowing) nappy bin, or express milk in an environment with feces hanging around (contrary to popular belief, baby poo contains similar bacterial concentrations levels to adult feces and can carry pathogens that spread disease). As I discussed previously, there is good evidence that breastmilk expressed in cleaner conditions stays safer for longer. Oh, and while you’re at it, please install chairs without arms; I don’t know what idiot decided that it’s easier to feed a baby in an armchair, but they clearly haven’t based this decision on experience. And could the sign on the door include a picture of a bottle and the International Breastfeeding Symbol, or something neutral, like a picture of a baby? 

 

I’m aware that all this may sound a little demanding. Still, installing a vending machine with bottled drinks and baby supplies might help cover some of the cost. Also, in the brave new world of online shopping that we now live in, brick-and-mortar retail is having to undergo a certain amount of reorganization; less focus on boring and functional provisioning, more emphasis on the fun and leisure aspects of shopping. Making sure that shopping is not a ghastly experience for parents is one obvious thing that malls and department stores can do to encourage parents to shop in their stores; shoppers these days expect nicer treatment as a reward for turning up. Supporting parents of all feeding styles and genders would be a win-win for everyone concerned.