Young Families in Israel Pay Twice for Formula Marketing

'Baby Leo' photo (c) 2010, Bridget Coila - license: 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.

My thoughts:

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.

Related posts:

Breastfeeding Law to Limit Formula Marketing in Hospitals

Haredi Public Shortchanged by Formula Freebies

Poor Weight Gain in Toddlers

Preparing for a Pesach Baby



  1. Its the babies that pay the highest price sadly.

    Perhaps hospitals should look at the big picture and take into account how much money would be saved in treating sick babies if mothers breastfed for longer, as well as how much money businesses would save as parents would take less time off to care for a sick child. In the US they estimate that $3.6 billion could be saved each year if 50 percent of mothers breast-fed their babies for six months.

  2. If anyone wants to encourage Israeli women to breastfeed, then the Knesset needs to extend longer maternity leave for mothers. Israel, supposedly a socialist country, offers a shorter period of maternity leave than Europe or Canada. It has to be hard for mothers to breastfeed if they are rushing back to full-time work and leaving their baby at a daycare for the whole day.

    • Chava, agreed, that is an important factor. Many European countries have 16 weeks, we have 14. Some have a year, but with our birthrate I don’t believe that it will ever happen.

  3. I may have said this before, but I don’t understand why the hospital has to provide formula at all. I think I’ve heard that in Canada, if a mother wants to formula feed she brings formula with her to the hospital when she gives birth. This would probably work well in Israel, where in general you don’t expect the hospital to provide stuff for you – if you’re bringing your own shampoo and diapers, why not your own formula? This would completely eliminate babies getting fed formula against their mothers’ wishes, and furthermore would not be paternalistic towards formula feeding mothers – on the contrary, they would be treated like capable adults who can find their own fomula and choose the brand they like best.

    • You’re right. But people do not like to pay for things they are used to getting for free.

    • It’s not Canada, it’s the UK and it’s a horrid policy that’s about saving money in the guise of promoting breastfeeding. It is viewed as paternalistic and overbearing. The policy was supposedly in operation when I had my older child in 2007. My daughter wound up in special care, where they aggressively pushed formula supplementation for ABO jaundice. (These policies do not apply to special care, only to elective formula feeding, increasing the perception of judgment.) I was post-section and coming off magnesium sulphate, so I was in no shape to argue. The problem with the policy is that the nursette bottles are not available retail there, so it becomes a logistical mess of half used cartons (the typical formats are 200ml RTF or powder) or having to boil, mix, and sterilize. British hospitals discharge within 24 hours for an SVD, which means the policy has very little long term effect in encouraging breastfeeding. And, as my experience shows, it does not stop babies being fed formula against their mothers’ wishes because it typically happens when the mother or baby is ill. I was asked, but exactly how was I going to say no when the nurse was telling me the neonatologist wanted it?

      After breastfeeding issues with both kids (finally diagnosed with IGT after #2) I have to say that staff training and support is really what’s key, not availability of formula. My 2nd was born in the US. If I wanted formula, my choice at the bottom of the bassinet (no exclusive contract). There were 2 IBCLCs on staff and all RNs were trained in basic breastfeeding. Night nursery was available but optional (24 hour rooming in encouraged) and when I used it the first night they asked if I wanted him brought back for feeding. When he went for bili lights, he was brought back for nursing. Whereas with #1, the SCBU nurses refused to let her be taken from under the lights except for bottles (no cups, no syringes, bottles only) and breastfeeding support was limited. At the time they were talking about eliminating the breastfeeding midwife altogether, and I think she still had other patients. She wasn’t there at the weekend at all, so if you gave birth then, no help. It also helped that ratios in the US are much better so the nurses have time to spend with the mothers, help them latch and position, etc.

      The UK has pretty comparable breastfeeding rates to the US, by the way. So much for longer leave. Most of my friends quit breastfeeding pretty quickly.

      • Ugh, NVD, not SVD. You know what I mean.

      • Okay, you convinced me. You don’t want a situation where someone didn’t bring their own formula and was forced to breastfeed. Although the cost could be added to their bill. Baby-Friendly hospitals do have formula on hand and they do not penalize mothers for not breastfeeding, as far as I know.

        • I still am not convinced. If I forget to bring shampoo to the hospital, I’m not being FORCED to not shower – I just need to send someone to run out and buy some for me, or ask my roommate to borrow hers. How can capable intelligent women who have been going to stores and buying products for many years suddenly say they are being forced to breastfeed just because the formula isn’t being doled out for free?

          • Your analogy is faulty. Do you have to shower every three or even two hours? Do you have to prepare the shampoo each time you shower, in a strange place, surrounded by strangers? When I was in hospital after giving birth I rarely had someone who could run out and buy anything for me. Granted someone would only have to run out once for formula, but it still has to be prepared fresh at each feeding. I am NOT advocating formula. I am quite opposed to it and used it only once, for a few days when I had a very temporary problem with my milk supply. I commented more fully below.

          • Hey, my roomate after my last birth hit the mall at Hadassah within hours of giving birth in a sheitel, makeup and sweater set. I’m not kidding. When I saw two nicely dressed charedi women walk in with shopping bags (thinking they were the visiting bubby and sister) while I was getting settled in my maternity ward room, I was shocked to discover that one of them was the new mother! And she had given birth a few hours before me.

          • Actually, the better analogy is that hospital patients are fed 3 meals a day, no questions asked and babies are patients as well, once they are born, so why wouldn’t they be offered food as well? So far, no one is demanding that hospital patients bring their own food.

            And new mothers are hampered in preparing formula properly at the hospital unless they are offered sterile bottles, sterile or boiled water and proper bottle washing facilities. Just expecting women to bring in their own formula does not solve the problem.

    • Some hospital provide everything(diapers, formulas, etc) and some don’t depending on the amount of women checked in, supplies available, size of hospital, etc.
      In Ontario, Canada (where I am) there is a huge support system for breastfeeding mums (also helps that we get 1 yr Mat leave & free community resources). There is no choice, babies are expected to room with mums unless baby or mum is sick, has complications, etc. In large hospitals there are breastfeeding consultants (& clinic) and most nurses are trained to help and support. There is almost a backlash against formulas feeding mums.
      With my first child, I was offered formula because her bilirubin levels were low. Formulas was offered but I refused. I was educated by my family dr., researched myself and was determined to breastfeed at all costs (I did for over a 1yr with both babies also had csection with both).
      I think for breastfeeding to be successful, baby needs to room with mother. Also for more education for mums & nurses. It sounds like nurses are the “pushers” for the formula- “…whose goal was to reduce the amount of crying in the ward.” Formula fed babies cry, too. I thought that was common knowledge 😉
      Great post. Going to pass it on to my relatives in Haifa.

      • Thanks, Selena. If Canada can have rooming in for all moms we can too.

        • First more women have to want it. Some of my exclusively breastfeeding neighbors are aghast at the concept. Personally, I like the OPTION of being able to put baby in the nursery so that I can sleep with full peace of mind if I’m particularly exhausted. Of course that’s only possible if the staff will call the mother to breastfeed when the baby wakes up. Fortunately I had that option.

          • Hadassah, I don’t think any women should be forced to room in if they don’t want to. But my sense is that right now in Israel more women want it then can have it. That is definitely the case in Hadassah Ein Karem, where I gave birth: they have one postpartum ward with full rooming in, and on our hospital tour we were told that that ward is pretty much always full and that many women who want it don’t get it just because of lack of space.

          • I think 24-hour rooming in should be the default for all babies, breastfeeding or not. The research is clear on the positive effects for baby. Moms get as much sleep and it does not affect their alertness the next day. I understand that many moms don’t want it but the hospital should be providing evidence-based care for its patients. Especially in a public hospital where full-rooming in saves money or at least frees staff for other tasks.
            I once attended a talk on breastfeeding after my birth. The LC pointed out that all 30 of the babies in the room were quiet. On the other side of the wall, we heard babies screaming at the top of their lungs. To me, that says it all.

          • I’m with you Hadassah. I exclusively bf for the first six months but I really liked having the option of a nursery. The one time I had to room in I was miserable.

    • Nurse Yachne says

      It’s not such a good idea for organizational reasons. The hospital has to provide uniform sterilized formula for those who need or want it, and bringing formula in from the outside would be even more of a balagan than bringing in expressed mothers milk already is. Mothers milk being irreplaceable, the outside introduction is worthwhile.

      • Nurse Yachne says

        “I think 24-hour rooming in should be the default for all babies, breastfeeding or not.”

        I liked rooming-in and I didn’t mind when they didn’t have it after one of my births, either. My daughter had a wonderful experience with rooning in for her first birth too.

        My sister-in-law *hated* rooming in, because she couldn’t leave the ward unless she had someone to mind the baby. For her, it was like being in prison, but the only place available at the time was rooming in.

        • That’s understandable. I wonder how they handle that in Canada. Surely you’re not expected to bring a newborn into the bathroom with you, for example.

          • The bathroom/shower are in your room. In a non private room (health care is free in Canada but you can pay extra for little upgrades) usually 2 women (occasionally 4 in older hospitals) share a room and showers are in the room or just across the hall.
            If it’s not too busy, nurses can take baby for a sort period of time. Husbands/partners are also encouraged to stay with mum and help. They can even room with mum in private rooms or in shared rooms- if there’s no one sharing. My husband stayed with me the first night to help.
            You’re also assigned a nurse (it changes as shifts change) who is your primary care giver. If you need help, you buzz, she/he comes to the rescue.

            I gave birth in a large older hospital- with my 1st- and a rural hospital (only 6 rooms and most doubled as birthing rooms) The nurse’s station was a across the hall. I had a 4.8kg baby who wanted to nurse all the time. The nurses offered to take him an hour or two here & there to give me a little rest. I found the experience to be quite nice and homey. A big change from the large hospital with my first baby where I was expected to keep baby with me at all times and felt a little lost in the shuffle
            I guess it’s nice to have a little of both…

          • Late, but in the UK you have bays of maybe 4-6 women (size varies by hospital; my postpartum bay was 6 beds) but toilet and shower are not off the bay, but in the corridor. Partners are kicked out at 8pm. It’s a problem.

            A nurse friend of mine told me that when rooming in is mandatory, Press-Ganey scores go down and women choose other hospitals. So in the US, it’s a marketing issue. That’s why the optional night nursery method has come up—it pleases enough women but encourages rooming in and is cheaper to operate.

            I have a somewhat different perspective. I’ve had 2 Caesareans, both with some complications. After my first (no nursery) I was left alone with the baby, hooked up to drips (I was severely preeclamptic), and with no one to help. My husband left (assuming I was going to be sent to the postnatal ward where he wasn’t allowed) and staffing was poor. As it turned out, I wasn’t in shape to go and so the baby and I were simply left in a post-surgical area. Obviously, this doesn’t say much about the hospital in general, but there really seemed to be no system in place for taking care of babies in situations like this. The midwives were too busy.

            Second time, I lost a lot of blood in surgery, my blood pressure tanked, and I felt awful; they were talking transfusion. It was pretty much unanimously agreed that the baby should go to the nursery overnight—my husband had work in the morning (saving his leave) and couldn’t stay. (I didn’t feel pressured by the staff but they did seem genuinely concerned; once I felt better, I didn’t get any pressure over using it.) He was nervous enough that he wouldn’t leave till he saw the nurse take the baby.

            That’s what makes me nervous about mandatory rooming in—what happened to me isn’t that unusual, and if there’s going to be complete rooming in there needs to be a system for taking care of babies when the mothers aren’t doing so well. With my first, they could probably have kept her with the special care babies overnight, since I wasn’t even in a regular ward, but healthy babies really don’t belong in there.

          • Alexis, yes, not every mother is up to caring for a baby post-partum.That’s why I used the term default instead of mandatory.

            For the record, if the mother can’t care for the baby on her own, she can still nurse as long as there is someone to place the baby on her chest. Just because someone else needs to care for the baby doesn’t necessarily mean the baby has to be fed formula. Ideally all mothers should be able to nurse if they choose. Unfortunately many hospitals don’t let newborns out of the nursery at night. So if the mother can’t get there on her own, her baby gets formula.

  4. I’ve seen Assaf Harofe and I believe it. The place looks like a camp hospital in Rwanda. Located at the entrance to the Tzrifin army base, it’s literally a series of “bunks/shacks” loosely connected by somewhat covered walkways. I wouldn’t want to give birth there unless I couldn’t hold my legs together to get to Beilinson or THS.

  5. I agree with Alexis on the importance of staff training and support. The decision whether or not to breastfeed is generally made before giving birth, so the advice giving during prenatal care is extremely important. After giving birth if breastfeeding is difficult and there isn’t good support staff at the hospital, even if the mother has breastfed because she hasn’t had formula available and even if she had every intention to breastfeed, she will all too often rush to purchase bottles and formula on the way home from the hospital if no-one has done so for her already. Also even if a baby has been formula fed in hospital at some feeding times against the mother’s wishes – which I agree is terrible – if the mother wants to breastfeed and has good support, especially from her local health care provider, she will breastfeed at home.
    Australia also does not provide formula in maternity wards. Does it ever happen that women, especially first time mothers, who are forced to either breastfeed or deal with preparing bottles in a unfamiliar communal environment develop a negative opinion of breastfeeding, because it is forced?
    I do agree that formula companies should not be allowed to market their products in any way through the hospitals – no deals, exclusive contracts or fun days for the nurses. Fortunately the free formula samples previously given on discharge from hospital have been stopped in Israel. Now the samples that arrive in the mail at home at regular intervals , Stage 1, Stage 2 Etc. must be stopped. I suppose I shouldn’t have been surprised that my address had been given to a formula company, but I was. Surprised and angered.

  6. I don’t know. All of my kids, except the middle one, got formula against my very explicit wishes. With the middle one, the story is more complicated. He was born big, almost 10 pounds, and despite all the literature and information to the contrary, he got really hungry within 12 hours of birth and I simply wasn’t producing enough to satisfy him. I was nursing and nursing and nursing and he was still starving. I was so exhausted, I gave in a gave him a bit of formula. I did that for two days until my milk came in. He hadn’t had formula ever again and was nursed well into toddlerhood. I was grateful to have free formula to tie us over until I was making enough to satisfy his hunger. Same thing happened with number 3 who was also 10 pounds, but I was ready for this turn of events. I wasn’t happy that the nurses didn’t seem to care that I wanted to nurse and never brought her to me. Ultimately, though, none of this affected our breastfeeding relationship. I think how successful and how long the mother is breastfeeding, barring health issues, is mostly dependent on how dedicated the mother is to breastfeeding. Everything else is not as important in the long run.

    • Agree 100%. It really comes down to what the mother wants and is capable of doing (very important- I know many mothers who really want to bf and try everything under the sun until they are bleeding, depressed and their babies are practically starving and it simply doesn’t work). I find assertions to the contrary to be almost patronizing of mothers, as if they don’t really know what they want and aren’t capable of making their own decisions.

      • Abbi, I know as well as anyone the serious and very real problems that mothers can have. I agree that this should be recognized. However, mothers still get a tremendous amount of misinformation from both hospital staff and pediatricians.

        • Unfortunately, I have found that misinformation is coming from both ends of the spectrum. Hospital stuff lies out of ignorance and convenience, and LLL happen to be extremists when it comes to nursing. They make every intervention sound like an insurmountable obstacle to breastfeeding relationship and every ounce of formula as an end of adequate milk supply. I understand where they are coming from – they had to fight against decades of bottle feeding, but it creates unnecessary anxiety. Their attitude that everyone can breastfeed no matter what (with very, very few exceptions) creates unnecessary guilt in those who do not succeed or supplement. I think women should be treated as adults and given accurate information, not be subjected to fear mongering. That’s why I think that having free formula in the hospital ultimately doesn’t make much of a difference in the long run. Those committed will remain committed to BF; those who don’t know enough about it to be easily swayed by free formula probably wouldn’t have BF exclusively in the first place.

          • I completely agree with you about accurate information. Breastfeeding helpers of all kinds should be well-trained, at least to refer mothers who are experiencing more than the normal difficulties if nothing else. But I can’t equate over-enthusiasm by breastfeeding helpers to corporate intervention in medical decisions in the hospital.

          • Nurse Yachne says

            “LLL happen to be extremists when it comes to nursing. They make every intervention sound like an insurmountable obstacle to breastfeeding relationship and every ounce of formula as an end of adequate milk supply”

            Too often true, in my experience.

            “Their attitude that everyone can breastfeed no matter what (with very, very few exceptions) creates unnecessary guilt in those who do not succeed or supplement. I think women should be treated as adults and given accurate information, not be subjected to fear mongering.”

            Yes indeed. And what you get is “Meet the new boss/Same as the old boss”, as The Who put it.

  7. It’s all well and good in theory, but there are practical, sanitary considerations. The free formula in the hospitals comes in the nursettes – which are one-use-only disposable bottles. They are so expensive, they don’t even sell them in Israeli stores because no one would buy them. Without the corporate deals, they would disappear. Do we want people bringing their own formula and bottles into the hospital, having to mix it, warm it, wash and sterilize bottles? Do we want the already-overworked nursing staff to get into the bottle-washing business? What about germs? What about kashrut?

    I agree with all the other suggestions about encouraging breastfeeding, rooming-in, etc. (except signing the waiver – that is condescending and paternalistic, making women who are in labor or post-partum declare they plan to be second-class mothers because they want to allow formula.) But I don’t think having free, convenient, safe, access to formula in the hospital for parents who want it or need it is a bad thing, and if the companies are willing to supply it, why not take it? I think the start of breastfeeding has little to do with the length of time it continues, that has everything to do with the circumstances of the mother’s life and her attitude. If Danon really wants to help, why doesn’t he legislate that the money from the formula companies must go to lactation consultants and free access to breast pumps for the mothers trying to breastfeed? I don’t like the paternalism of protecting the ignorant mothers and helpless babies from the evil formula companies. Let’s allow women to decide and respect those decisions.

    • Allison, it’s simply unethical to have formula company money go to lactation education. A clear conflict of interest. The only way to keep formula marketing out of the hospital is to require the hospitals to buy the formula at cost. The companies are only interested in contributing if they get something back, i.e. exposure to new mothers.
      I agree with you that mixing powdered formula is risky. I have seen a recommendation that babies should get ready-to-feed formula until two months, but can’t find the source at the moment.

    • Okay, THAT is a reason I can accept for allowing hospitals to provide formula. Fair enough.
      But I still am concerned about the distorted picture of breastfeeding vs. bottlefeeding that new mothers get in Israeli hospitals. In Israeli hospitals, formula feeding is free and ridiculously easy to do. Breastfeeding, on the other hand, is difficult – aside from the inherent challenges in figuring it out, if you want to do it at night in most hospitals, you have to get out of your warm bed and sit in some chair in the nursery, while formula feeding mothers peacefully sleep through the night. And it’s also more expensive – formula is handed out for free, but if you need nursing cream, nursing pads, nipple shield, etc, you have to send someone off to the drugstore to buy them for you.
      What a shock it must be for formula feeding mothers who come home from the hospital and discover that in reality, formula feeding is expensive and a lot of work! Meanwhile breastfeeding mothers get home and realize that they can keep their baby nearby at night and not lose nearly as much sleep as the bottlefeeding mothers, and once the original challenges are sorted out breastfeeding becomes easier and much cheaper.
      I think it would do a service to mothers to have the realities at home more accurately reflected in their time in the hospital, instead of the current distortions.

    • Kashrut is not an issue. All you need is boiling water from a kettle. The formula doesn’t even need to go into a pan.

    • I saw that when it came out. What about the babies who get formula against the express wishes of their parents? Don’t they have rights as well?

      • When it comes down to it, my right to ensure that my baby doesn’t get exposed to formula trumps the rights of adult women not to feel guilty or the victims of paternalism. I don’t care whether the form lists the risks of formula or whatever–take them out if that is the concern.

        • But if your goal is to encourage more women to have a positive attitude towards breastfeeding, how does the form, which makes women feel guilty and patronized, encourage this goal?

          • Giving the babies formula against the mother’s wishes is much more paternalistic and condescending. The point of the form is to make it clear to the hospital that this policy is wrong. There shouldn’t be a need for such a form.

          • The problem is that you have a group of women who want to breastfeed, a group who want to bottlefeed and a group who could go either way. It seems you’re ruing in the chances of more babies (2/3 of these groups) getting breastfed in the long run by pushing a form in their faces that makes them feel bad or negative about breastfeeding. You might be right, but strategically, if your goal is for more babies to have breastmilk, I don’t see how the form encourages this. What’s that proverb? Better to be smart than be right?

          • Abbi, people sign consent forms all the time with all kinds of dire warnings.

            It’s silly to feel guilty because of signing a form. The form does not say that bad mothers give formula. It lists the risks of formula, which is, to reiterate, a medical intervention. The risks are real–read the AAP report. If your baby really needs the formula, you shouldn’t feel guilty. If you prefer to bottle-feed, you won’t feel guilty. If giving formula makes you feel guilty, don’t sign the form and don’t give the formula. I really don’t understand the uproar over a form.

            Also, how do you know that the form will give people a bad feeling about breastfeeding? Maybe the idea of the form will help them stick it out longer and end up enjoying it. You assume the form will lower breastfeeding rates, but we don’t really know.

          • In all of the articles and online forums that discuss the issue, the consensus is that the form leaves, at the very least, a bad taste in mother’s mouths. In my experience in education, negativity doesn’t usual make people want to stick with something more.

            Also, what about the mothers who need to give formula for medical reasons but feel guilty anyway? Why make a difficult post birth situation more difficult by making them sign this form?

            The uproar about the form is turning something everyday and something you can walk into any supermarket or pharmacy and purchase in abundance without a prescription into something suddenly medically “dangerous”. Even if you have some science on your side, people don’t buy it. Not after 50 years of OTC use.

  8. There are two separate issues here regarding the early supplements.
    1. The recommendation is for six months of exclusive breastfeeding. Hospital policies should help ensure that exclusive bf doesn’t end at one or two days of life.
    2. Whether or not free formula and marketing influences a mother’s breastfeeding options or choices down the road. This is less of an issue for me.

  9. This is really interesting to me… and my experience in two Israeli hospitals has been very very different than the accusations I have read about in the media. (i.e. very pro-BF and supportive and no one gave my babies formula or even tried to).
    I really think that the focus of availability of formula in hospitals is a very minor factor in the question of why so many women wean early or don’t BF. Let’s face it, BF is hard – even if it goes well, it’s significantly less convenient than FF. Most people think it doesn’t really matter what the baby eats, and while we have plenty of research that says otherwise, people see tons of babies every day having formula and turning out fine, so it doesn’t seem very real.
    I think it’s like the fast food debate – people know it’s crap that will lead to poor health, but they eat it anyway. Is the answer making it less available? I really don’t know…

    • Thanks Lauren for sharing your experience. The point is not to make formula less available, but to get huge corporations out of our health facilities, and letting money–instead of science–influence behavior of medical staff and parents.

      • I’m going to chime in with Lauren. I gave birth five times in Israel and was in two hospitals, Barzilai, Ashkelon and Ma’anei HaYeshou’a, Bnei Brak for a total of 18 days; one of my newborns was in the NICU for 5 days after I was discharged by choice. None of my children were ever given formula without my consent and only one received it at all. One of them needed a bit of supplement in the NICU, but I was strongly encouraged by the entire staff to increase my milk supply and exclusively breastfeed, which I did. None of my friends, virtually all of whom breastfeed for at least the first few months, ever complained of hospitals giving formula without consent, and I haven’t heard stories of nurses pushing formula. I have heard too many stories of women not being advised of the benefits of breastfeeding or not receiving enough encouragement in the beginning. One of the nurses at Ma’anei HaYeshou’a said it would be a crime to give a baby formula when the mother requested to exclusively breastfeed. My baby hadn’t been brought to the nursery yet so the “breastfeed exclusively” sign wasn’t on her bassinet yet. She arrived while I was speaking to the nurse and the sign was immediately affixed. I had roomed-in at Barzilai and technically couldn’t at Ma’anei HaYeshou’a, but I kept my baby with me all day except for check-up times. I desperately needed complete rest at night so I didn’t even try to keep her with me, but if I had wanted to, I would have snuck her behind the curtain. The staff was extremely conscientious about waking up breastfeeding mothers as soon as the babies woke up.
        Yes, babies who are formula fed “turn out fine”, but they’ve suffered a lot more stomach-digestive problems, have more allergy and weight problems, and are sick much more frequently, all of which put a strain on the entire family, not just baby. I doubt most soon-to-be mothers are informed of the statistics. Do formula fed babies cry more? Women at home on maternity leave should definitely be informed that their babies will be much more comfortable breastfeed, and we all know that a comfortable baby helps Mom be comfortable. Is formula feeding really more convenient, especially when Mom is at home?

  10. I think it’s being a little naive to think it’s possible to “get corporations out of our health facilities”. As citizens we are taxed as much as we can be in order to provide universal health care and there will always be a shortfall. And corporations will always step in to fill that shortfall because it benefits both parties (hospitals and corporations).

    In terms of influence, I have always wondered why you never speak of lobbying for an overhaul of the nursing programs that would require every nurse who intends to work on a maternity ward to take LC classes and all head nurses should also be IBCLC’s. The nurses, and particularly the head nurses are the ones who determine the attitude towards formula. If the complaint is how nurses are really “formula pushers” than wouldn’t pushing for nursing school reform be the most strategic way for increasing breastfeeding rates? You don’t have reps from Similac and Materna feeding the babies formula on wards. It’s the nurses. So why doesn’t the reform start with them?

    • All the nurses with whom I came in contact had more than basic LC knowledge. Difficult problems were referred to the official LC. There was one great nurse who told mothers to come to her because, “Everyone eats with me!” Sure enough, she succeeded, time after time.

      • Hadassa, that’s a nice story!

      • Hadassa- most nurses I’ve come into contact have been very bf friendly. The older ones tend to be less so. The head nurse at Meir is staunchly pro bf, to the point of refusing to give out nipples for pacifiers and all the nurses there were able to help me with positioning. And it makes a huge difference. Which is why I don’t understand why the focus isn’t on the nurses.

    • We should keep in mind that a woman after giving birth is, in many cases, especially with first time mothers, a very vulnerable potential customer and that some of what formula companies do is “putting a stumbling block before the blind”. Asking a stressed, overworked nurse to stand up to pressure from the formula companies when pressure from the companies could be reduced or all together eliminated isn’t right either.

      • Ms. Krieger says

        Hadassa makes a good point. First time parents are very vulnerable and easily influenced, and their habits permanently changed. Retailers of all sorts in the US recognize this and go to extreme lengths to market to new parents. The department store Target actually had statisticians work out a way to identify pregnant women through their purchasing patterns so that it could market to them before they even give birth (and even predict due dates, etc.) Frankly unethical, to my mind.

    • Abbi wrote: “In terms of influence, I have always wondered why you never speak of lobbying for an overhaul of the nursing programs that would require every nurse who intends to work on a maternity ward to take LC classes and all head nurses should also be IBCLC’s. The nurses, and particularly the head nurses are the ones who determine the attitude towards formula.”
      There are breastfeeding courses offered to nurses throughout the country and have been for years. Some of these nurses go on to become IBCLCs. (By the way, I’ve heard that the hospitals are frustrated when the nurses get the IBCLC and try to change the antiquated hospital practices.) The health ministry is also offering a new type of breastfeeding certification, but it is not as rigorous. I am certainly in favor of education. But while the government is spending money for BF experts to train nurses (as it should), it is giving formula reps free reign right on the hospital floor to “educate” these nurses.
      Whatever readers personally feel about rooming in or supplemental bottles or pressure to breastfeed, surely they should be outraged at formula companies having such easy access to the health professionals who work with mothers.

  11. Having just given birth to my second, I have very strong feelings about what I do see is the fanatical insistence upon nursing and rooming in by various consultants. With my first baby, I nursed for a year….a very long stressful year in which my milk supply was terrible, I was in pain most of the time and I was made to feel guilty for every formula bottle, so I spent hours pumping (instead of sleeping). It was awful and had all sorts of negative effects…and yes, i had consulted many lactation consultants.

    This time around, –my son is 4 weeks old–it is going beautifully. Why? B/c I got over my guilt and ignored all those die hard-must never give formula fanatics. I have so much milk this time that I”m leaking and spraying all over the place. I really attribute it to not being stressed out. My son has gained a ton of weight…..and i feel no guilt over giving him up to one bottle of formula day (if needed) and I let the hospital where I did not room in (NO NO NO to default rooming in…NO)…..give him one bottle of formula a night. The ability to sleep at least 3 hrs straight was huge. Plus, I also had normal lactation consultants who focused on technique. the first few days were really tough…my nipples were cracked, bleeding and sore…but i got past it my giving myself a break (using nipple shields) and not being guilted into pumping. And NOT pumping is such a good decision as well…..the ability to walk for an hour or clean my house does a lot more for my health and sanity (and therefore my milk supply and the baby’s health) than pumping would.

    This is the long way of saying that I 100% believe in the benefits of nursing, and plan to continue nursing (even when I go back to work) etc etc…but i really believe that telling women they can’t ever not nurse or that even one bottle of formula is evil does a terrible disservice and backfires in the long run (it certainly did for me this first time around)..adn I just vowed to do it differently this time by tuning out that kind of advice.

    I really love this blog…but your stance on breasfeeding/rooming in always gets me upset b/c it is precisely that kind of thinking which created a terrible first year for me with my first kid.

    • Hi Leah,
      Mazal tov on your new baby!

      It is great that you found ways to make this breastfeeding experience easier for you. There is no problem with a mother deciding to give her baby a bottle of formula. The problem is if the mother doesn’t want to give that bottle and is pressured into it, or that the hospital gives a bottle against the mother’s wishes. Or if the mother isn’t given support and information to make the best decision for her and her baby. You made your decisions, after receiving the help of lactation consultants, which is a service that all new mothers deserve but don’t always have available.

  12. I know a great way to keep babies quiet AND keep moms from bugging the nurses: PUT THE BABIES WITH THE MOMS! You wrote, “This medical intervention should require authorization, unless the baby’s health is at risk.” Unfortunately I can see many pushy Israeli nurses convincing Moms their baby’s health is at risk for minor issues – jaundice, normal weight loss, crying… Isn’t that why most babies are separated from their moms even in hospitals that claim to offer rooming in? Still, the form might help get the idea across that nursing should be the default. Formula is not a choice, it’s an intervention. Everything mother and baby experience in the first days and weeks should be to encourage health and bonding (NURSING). Unfortunately hospitals are just about the worst place for this endeavor.