The Knesset economic committee met this week to discuss the law limiting formula marketing in Israeli hospitals.
Last Friday, Haaretz published an article by Ruti Levi on the arrangements between formula companies and hospital maternity wards.
Currently, the companies pay large sums in order to ensure sole distribution of their products to new mothers. Israel is a signatory to the World Health Organization’s International Code of Marketing Breast-Milk Substitutes, abbreviated to the WHO Code. According to the Code formula companies may sell their products, as long as they don’t market them to new parents through giveaways, coupons and the like. Health professionals may not accept perks or training from these companies, other than instructions on how to use their products correctly. But the Code is rarely enforced here.
Elah, interviewed in the article, gave birth three months ago. She describes a battle in the maternity ward between the lactation consultants, who were “nearly fanatical” in their encouragement of breastfeeding, and the nurses, whose goal was to reduce the amount of crying in the ward.
Since the consultants only worked in the morning, the nurses who offered formula at every interaction with Elah (“only 30 cc”) [HK: more than a complete feeding for a newborn], it’s clear who usually wins. And even though Elah is still breastfeeding, she got formula samples and coupons in the mail three weeks after birth. [Coincidentally (not!), one study showed that three weeks was the most common age for weaning among Israeli women.]
Haaretz points out that the battle is not between nurses and LCs, but between the formula companies themselves, who know that 60% of the mothers will continue to use the formula brand they were offered in the hospital. It’s all about money.
Additional points mentioned in the article:
- The companies demand that the hospitals distribute their formula exclusively. In return the hospitals receive payment, equipment, and unlimited amounts of ready-to-feed formula. Total cost: NIS 50 million annually, distributed among 26 hospitals.
- Only two of the four companies distributing formula in Israel have arrangements with hospitals. These two companies control 97% of the formula market.
- The hospitals publish a tender every 1-5 years, and whoever offers the most money is the winner. So small companies can’t break in.
- Materna pays 2.6 million to Tel Hashomer. Similac pays NIS 7 million for hospitals affiliated with Clalit, including Meir, Beilinson, Soroka and Kaplan with their large maternity wards. Assaf Harofe hospital admitted that 90% of their decision regarding the tender is based on the amount offered.
- The government pays hospitals NIS 11,200 for each regular birth and 170,000 for each premature birth.
- In the end, consumers pay the cost of marketing. Parents here pay 18% more for infant formula than in the US, 64% more than in Britain, and 49% more than in Australia.
- The “law promoting breastfeeding and preserving the method of feeding” of MK Danny Danon is meant to address the high costs of formula. The law will require hospitals to buy formula at cost and distribute it without a brand name. This will neutralize the economic interests of the hospital, weaken the power of the larger companies, and promote competition and lower costs.
- Materna says in a letter that the agreements with hospitals add 9% to the cost of the product, which go to the hospitals. Danon says that Materna makes 40% profit on each container, and some populations must dilute formula because of its price. Materna promises to lower prices by 9% upon the passage of the law.
What about breastfeeding?
- Hospitals are complaining that without these funds, they won’t be able to offer services to new mothers like the breastfeeding room in Assaf Harofe hospital. The hospital has only one part-time LC. [HK: I’m not sure whether the doctor quoted was saying that the LC is funded by formula money. Assaf Harofe has 8000 births a year, which translates to eight babies per hour of lactation consultation.) Some formula money goes toward hiring medical clowns. The hospital administrator says, “Every piece of equipment from the EKG and up must come from donations. If we will cut this significant source of funding, we will have a problem.”
- A representative of the formula market says that the cost of the formula is insignificant to the hospital, and breastfeeding support begins with the hospital staff.
- Danon denies this, saying that hospitals fear the law because the next step will be to examine their relationships with drug companies. The formula companies “live in the hospital” and take nurses out for “days of fun.” The propaganda is clever. Nurses know what they get out of the relationship and feel obliged to produce results. Once marketing is removed, the forces won’t be as strong. In the long run the law will save the state millions of shekels on health expenses.
- Galit Avishai, director of the consumer organization “Imun Hatzibur”, maintains that the health ministry should be responsible for funding breastfeeding rooms and nurses. It should not participate in a scheme that causes consumers to pay extra costs.
- Kadima MK Rachel Adatto says that the health ministry, not the Knesset, should be responsible for the regulation. A representative of the Health Ministry said it supports the proposed law.
- Levi writes that until this is resolved, whether by law or regulation, parents will be captive consumers with the hospitals and formula companies laughing all the way to the bank.
Proposed law makes mothers angry
The proposed law includes a statute requiring mothers to agree that their babies can receive formula. Meant to please mothers and women’s organizations, Danon admits that it has aroused the most controversy.
The form includes information about the risks of formula and benefits of breastfeeding, and many mothers see it as paternalistic and interfering with their free choice. The hospitals object to it as well, claiming it will increase bureaucracy. Danon indicated that the idea for the form came from the WHO Code, but he is open to changes in that part of the law.
I do support requiring permission from parents before giving formula to babies. The parents can sign the form at check-in. If hospitals can find a way to get mothers to sign forms agreeing to cesarean sections they can handle this too. Babies are frequently fed formula against the mother’s wishes. This medical intervention should require authorization, unless the baby’s health is at risk. But I realize that the law has a better chance of passing without this provision.
The article mentions competition among the brands of formula, and minimizes the fact that the formula companies are competing against breastfeeding. Mothers who plan to breastfeed and stop (often because their milk supplies have dropped thanks to free supplements) are also more likely to use formula for longer than moms who didn’t plan to breastfeed in the first place
There are many reasons why moms don’t succeed at breastfeeding. Newborns rarely need supplements. The Academy of Breastfeeding Medicine has published a Protocol on Formula Supplementation outlining the situations where it should be used. When health care professionals offer formula in the absence of medical necessity, they send a strong message that breastfeeding alone is not sufficient.
The hospital setup also needs to be changed, with 24-hour rooming-in becoming the default arrangement. According to the AAP’s just-published policy statement on breastfeeding:
. . . breastfeeding should begin within the ?rst hour after birth (even for Cesarean deliveries) and . . . infants must be continuously accessible to the mother by rooming-in arrangements that facilitate around-the-clock, on-demand feeding for the healthy infant.
As for health ministry regulations, I wonder whether the ministry is strong enough to stand up to corporate interests without the backing of the law.
I understand that pharmaceutical giant Teva, which began importing formula last year, is funding this law. So I will be surprised if the law leads to a significant reduction in the cost or use of formula. The companies will simply divert their funds to more aggressive marketing to new mothers before and after birth.
Currently, mothers in Israel pay twice: Once when their babies get unnecessarily formula, which could compromise the baby’s health and is associated with lower rates and duration of breastfeeding. They pay a second time via exorbitant prices for a product they might not have needed in the first place.