Breastfeeding Rates and Gift Packs

A Critical Evaluation of a Recent Study on the Impact of Commercial Hospital Discharge Packs on Breastfeeding

A recent study, “Infant Formula Marketing Through Hospitals: the Impact of Commercial Hospital Discharge Packs on Breastfeeding” was published in the American Journal of Public Health in the February 2008 edition.¹ In this study, the authors examined data from the 2000 and 2001 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women (n=3895), to determine the relationship between exclusive breastfeeding and the receipt of commercial hospital discharge packs (CHDPs).

The authors reported that women who received CHDPs containing formula were more likely to exclusively breastfeed for fewer than 10 weeks than were women who had not received CHDPs. In addition, the authors reported that there was no association between nonexclusive breastfeeding for at least 10 weeks and a mother’s receipt of a CHDP.  However, it is important to note that the authors report significant unadjusted odds ratios at 2, 6, and 10 weeks, but do not mention the results after adjustment for confounders at 2 and 6 weeks (only for 10 weeks), nor do they indicate if there were data for later points beyond 10 weeks in the survey for which no significant effects were found.

This is not the first study to examine the receipt of CHDPs and infant feeding decisions.  As the authors described, “since the early 1980s, there have been many studies, of widely varying quality and conclusions, of the impact of CHDPs on breastfeeding.”  Of the five studies cited by the authors that compared receipt of discharge packs with formula versus receipt of no discharge packs or of discharge packs without formula, two studies showed an association and three studies showed no association respectively. The present study used a database of information that was over five years old (data from the 2000 to 2001 PRAMS survey). Infant feeding practices have changed over time. In fact, recorded breastfeeding rates in the United States have increased during the past decade, even as CHDPs have continued to be made available.  It is not known how the present study, which is based on older data, may reflect current infant feeding decisions and practices.

Another concern is that while the authors attempted to control for some variables that might have been associated with exclusive breastfeeding, such as education and maternal age, they did not report data on or control for other important variables, such as maternal employment. Maternal employment is one of the most common reasons women cite for cessation of exclusive breastfeeding.  A 2006 study by Ryan et al. found that mothers who were not employed were more than twice as likely to breastfeed at six months than mothers who worked full time.²  Further, one third of mothers return to work within three months of giving birth and mothers cite “going back to work” as one of the most important reasons not to continue breastfeeding.² The findings of this study could be explained by women returning to the workforce.  Although some employers offer six weeks of paid maternity leave and the Family Medical Leave Act (1993) provides for up to 12 weeks of unpaid leave, the majority of working women in the United States are in hourly paid or minimum wage jobs and simply cannot afford not to work. ²

Furthermore, the authors also failed to control for smoking, which is a general indicator of maternal healthy behavior. The mothers who breastfed less than 10 weeks were much more likely to be smokers than those who breastfed for 10 weeks or longer. Given the small association found in this study, it is quite plausible that mothers exclusively breastfeed longer because they themselves were more health conscious, rather than any effect from receipt of a CHDP. 

Another limitation of this study is its retrospective design; the survey instrument was not designed for this purpose (i.e. measuring the impact of CHDPs). The authors acknowledged there was a potential for recall bias, as there were no data proving women could accurately remember receiving a CHDP.  More importantly however, is that the receipt of a CHDP was not a random event. Both hospitals and health care professionals could choose whether and how to distribute CHDPs. Furthermore, mothers could choose whether to receive a CHDP or not. Some previous studies have attempted to control for this by intentionally providing or not providing CHDPs, or providing CHDPs with or without infant formula samples. The present study did not have such controls nor collected any data on how mothers had planned to feed their infants.  The majority of mothers report they make the decision about how to feed their newborn baby before giving birth.^3-5  In addition, most mothers (more than 9 out of 10) approve of “doctors, hospitals and clinics providing free samples of formula to new mothers.”⁵  It is not known whether in the present study, mothers who received CHDPs were actually more likely to choose to receive the CHDPs because they had already made the decision to not exclusively breastfeed for an extended period of time.

The authors are correct to conclude that, in their study, causality cannot be established. In fact, while the authors acknowledge that for more than 40 years, formula manufactures have provided hospitals with CHDPs containing an infant formula sample, data show that during this same time, United States breastfeeding rates have significantly increased and reached record highs.  

Lastly, the data were not taken from a representative national sample but were representative of only one state, Oregon, which has the highest rates of exclusively breastfeeding women in the entire United States. Based on this limitation, the authors concluded that their study “cannot be generalized beyond Oregon.” 

Mothers should be allowed full access to all available information on infant feeding options and practices, as well as samples, where and when the mother and/or the infant’s healthcare provider find it appropriate. This enables informed infant feeding decisions.

References Cited:

1 Rosenberg, K. D., Eastham, C.A., and Kasehagen, L. et al.  Infant Formula Marketing Through Hospitals: the Impact of Commercial Hospital Discharge Packs on Breastfeeding.  American Journal of Public Health.  2008; 98 (2): 290-295.

2 Ryan, A.S., Zhou, W., Arensberg, M.B.  The effect of employment status on breastfeeding in 
  the United States.  Women’s Health Issues.  2006; 5: 243-251.

3Bailey, V., & Sherriff, J. Reasons for the early cessation of breastfeeding in women from lower socio-economic groups in Perth, Western Australia.  Australian Journal of Nutrition & Dietetics.  1992; 49; 40-43.

4 Dix, D. Why women decide not to breastfeed.  Birth. 1991; 18: 222-225.

5 Fairbank, Maslin, Maulin & Associates.  National Survey on Infant Feeding.  July/August 2005.