Breastfeeding: Some Strategies Used to Market Infant Formula May 
Discourage Breastfeeding; State Contracts Should Better Protect  
Against Misuse of WIC Name (08-FEB-06, GAO-06-282).		 
                                                                 
Millions of U.S. mothers and infants each year forgo the health  
benefits of breastfeeding and rely on infant formula. Infants who
are breastfed are less likely to develop infectious diseases and 
chronic health problems, such as diabetes and asthma, while	 
breastfeeding mothers are less likely to develop certain types of
cancer. Recognizing the health benefits of breastfeeding for	 
infants and mothers, the U.S. Department of Health and Human	 
Services' Healthy People 2010 campaign has recommended that more 
U.S. infants be breastfed and that babies be breastfed for longer
periods of time. According to the U.S. Department of Agriculture 
(USDA), the U.S. would save a minimum of $3.6 billion in health  
care costs and indirect costs, such as parents' lost wages, if	 
breastfeeding increased to meet these Healthy People goals.	 
Breastfeeding rates are particularly low among infants who	 
participate in the Special Supplemental Nutrition Program for	 
Women, Infants and Children (WIC). WIC is administered by the	 
USDA's Food and Nutrition Service (FNS) in cooperation with state
and local agencies. The program provides free food and infant	 
formula to improve the health and nutritional well-being of	 
low-income women, infants, and young children. Nearly half of	 
infants born in the U.S. receive benefits through WIC. Although  
formula manufacturers agree that breastfeeding is best, they	 
market infant formula as an alternative for mothers who do not	 
exclusively breastfeed. A congressional committee asked us to	 
review the potential impact of infant formula marketing on	 
breastfeeding rates, especially for infants in the WIC program.  
We answered the following questions: 1) What are the estimated	 
breastfeeding rates for infants in the general population and for
infants on WIC, and how do these rates compare to recommended	 
breastfeeding rates? 2) How is infant formula marketed to women  
in general and to women on WIC in particular? 3) What is known	 
about the impact of infant formula marketing on the breastfeeding
rates of women in the general population and women on WIC?	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-282 					        
    ACCNO:   A46497						        
  TITLE:     Breastfeeding: Some Strategies Used to Market Infant     
Formula May Discourage Breastfeeding; State Contracts Should	 
Better Protect Against Misuse of WIC Name			 
     DATE:   02/08/2006 
  SUBJECT:   Child nutrition					 
	     Children						 
	     Food programs for children 			 
	     Health statistics					 
	     Infants						 
	     Marketing						 
	     Parents						 
	     Statistical data					 
	     Surveys						 
	     Women						 
	     Breast feeding					 
	     Infant formula					 
	     HHS Healthy People 2010 Initiative 		 
	     Special Supplemental Nutrition Program		 
	     for Women, Infants and Children			 
                                                                 

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GAO-06-282

     

     * Studies of Infant Formula Discharge Packs Included in Our Re
     * Study of Prenatal Infant Formula Advertising Included in Our
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GAO

                                 February 2006

BREASTFEEDING

  Some Strategies Used to Market Infant Formula May Discourage Breastfeeding;
        State Contracts Should Better Protect against Misuse of WIC Name

GAO-06-282

Contents

Letter                                                                   1 
Appendix I             Briefing Slides                                   6 
Appendix II            Advertising Data                                 36 
Appendix III           Literature Review                                37 
Appendix IV                 Studies in Literature Review                39 

                                 Abbreviations

CDC              Centers for Disease Control and Prevention                
FNS              Food and Nutrition Service                                
NIS              National Immunization Survey                              
USDA             United States Department of Agriculture                   
WIC                      Special Supplemental Nutrition Program for Women, 
                    Infants, and Children                                     

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.

United States Government Accountability Office Washington, DC 20548

February 8, 2006

The Honorable Robert Bennett Chairman The Honorable Herb Kohl Ranking
Minority Member Subcommittee on Agriculture, Rural Development,

and Related Agencies Committee on Appropriations United States Senate

The Honorable Henry Bonilla Chairman The Honorable Rosa L. DeLauro Ranking
Minority Member Subcommittee on Agriculture, Rural Development,

Food and Drug Administration, and Related Agencies Committee on
Appropriations United States House of Representatives

The Honorable Tom Harkin Ranking Minority Member Committee on Agriculture,
Nutrition, and Forestry United States Senate

Millions of U.S. mothers and infants each year forgo the health benefits
of breastfeeding and rely on infant formula. Infants who are breastfed are
less likely to develop infectious diseases and chronic health problems,
such as diabetes and asthma, while breastfeeding mothers are less likely
to develop certain types of cancer. Recognizing the health benefits of
breastfeeding for infants and mothers, the U.S. Department of Health and
Human Services' Healthy People 2010 campaign has recommended that more
U.S. infants be breastfed and that babies be breastfed for longer periods
of time. According to the U.S. Department of Agriculture (USDA), the U.S.
would save a minimum of $3.6 billion in health care costs and indirect
costs, such as parents' lost wages, if breastfeeding increased to meet
these Healthy People goals.

Breastfeeding rates are particularly low among infants who participate in
the Special Supplemental Nutrition Program for Women, Infants and Children
(WIC). WIC is administered by the USDA's Food and Nutrition Service (FNS)
in cooperation with state and local agencies. The program provides free
food and infant formula to improve the health and nutritional well-being
of low-income women, infants, and young children. Nearly half of infants
born in the U.S. receive benefits through WIC.

Although formula manufacturers agree that breastfeeding is best, they
market infant formula as an alternative for mothers who do not exclusively
breastfeed. A congressional committee asked us to review the potential
impact of infant formula marketing on breastfeeding rates, especially for
infants in the WIC program. 1 We answered the following questions: 1) What
are the estimated breastfeeding rates for infants in the general
population and for infants on WIC, and how do these rates compare to
recommended breastfeeding rates? 2) How is infant formula marketed to
women in general and to women on WIC in particular? 3) What is known about
the impact of infant formula marketing on the breastfeeding rates of women
in the general population and women on WIC?

On December 14, 2005, we briefed interested congressional staff on the
results of our analysis. This report formally conveys information provided
during that briefing. In summary, we reported the following findings:

     o WIC and non-WIC breastfeeding rates fell short of most national goals,
       but rates were substantially lower for WIC infants.
     o Infant formula marketing targets non-WIC mothers and also reaches WIC
       mothers. Some of these marketing efforts use the trademarked WIC
       acronym in promotional materials. Although FNS requires states to
       restrict this practice in their WIC contracts, most states do not.
     o A majority of studies we reviewed that examine giving free formula
       samples to mothers at hospital discharge found lower breastfeeding
       rates among both WIC and non-WIC mothers. However, little is known
       about the impact of most types of marketing.

In order to better protect the WIC acronym and logo from being
inappropriately used in infant formula advertisements, we are recommending
that the Secretary of Agriculture educate all states about

The Senate Committee on Appropriations asked in the 2005 Agriculture,
Rural Development, Food and Drug Administration, and Related Agencies
appropriations report (Senate Report 108-340) that we conduct this study.

Page 2 GAO-06-282 Breastfeeding

FNS' policy restricting the use of the WIC acronym and logo and ensure
that all state formula contracts include provisions restricting the use of
these trademarks in infant formula advertisements.

We used the following methodologies to develop our findings. To identify
breastfeeding rates, we analyzed 2004 data from the Centers for Disease
Control and Prevention's (CDC) National Immunization Survey (NIS) and
compared the breastfeeding rates of WIC and non-WIC infants to the Healthy
People 2010 breastfeeding goals. We also interviewed officials regarding
survey methodology, and we determined that the survey and analysis were
sufficiently reliable for the purposes of this briefing. To examine how
infant formula is marketed to women in general and women on WIC, we
analyzed data from market research company TNS Media Intelligence on
television, radio, print, and outdoor infant formula advertisements
between 1999 and 2004. To assess the reliability of the data, we talked
with company representatives about data quality control procedures and
reviewed relevant documentation. We determined the data were sufficiently
reliable for the purposes of this briefing. To supplement the data, we
surveyed state WIC directors and conducted interviews with women on WIC
and with officials from infant formula companies and the National WIC
Association. We also corresponded with FNS and reviewed state infant
formula contracts, FNS policies, and infant formula advertisements. To
assess the impact of infant formula marketing on breastfeeding rates of
non-WIC and WIC participants, we reviewed U.S. studies published between
January 1980 and July 2005 on the impact of infant formula marketing on
breastfeeding rates. We examined each study's research methodology,
including its sampling frame and analytic techniques, to determine whether
the results should be included in our findings. Only two of the studies we
reviewed included mostly WIC participants, and these studies had small
samples. For additional information on our study review, please see
appendixes III and IV. We conducted our work from June 2005 to November
2005 in accordance with generally accepted government auditing standards.

This study focused on the marketing of infant formula and its impact on
breastfeeding rates. We did not assess the impact of other factors that
may affect breastfeeding rates, such as cultural factors and whether women
work outside of the home, because this was beyond the scope of our work.
In addition, available data did not allow us to assess whether there is a
causal relationship between trends in infant formula marketing and
historical breastfeeding rates in the U.S.

We provided a draft of this report to officials of the U.S. Department of
Agriculture for review and comment and incorporated their comments where
appropriate. On January 6, 2006, the officials provided us with oral
comments. They stated they agreed with our recommendation that the
Secretary of Agriculture educate all states about FNS' policy restricting
the use of the WIC acronym and logo and ensure that all state formula
contracts include provisions restricting the use of these trademarks in
infant formula advertisements.

The officials noted that it may be necessary to include language in the
state contracts allowing for fair use of the WIC name and acronym, as
allowed by federal trademark law. They also explained that such use may
serve a helpful purpose by informing health care providers and WIC
participants of the infant formulas and medical foods that are available
through WIC. We noted that our recommendation language was sufficiently
broad to allow USDA to include language it considers appropriate in
protecting the WIC trademark, including allowances for fair use.

Officials also noted that the report did not consider the impact of
employment factors on breastfeeding rates and that such factors may be
particularly important for WIC participants, many of whom are employed
outside the home. We agreed and explained that assessing the importance of
such factors was beyond the scope of this report.

We are sending copies of this report to relevant congressional committees
and other interested parties and will make copies available to others upon
request. In addition, this report will be available at no charge on GAO's
Web site at www.gao.gov. If you or your staff have any questions about
this report, please contact me at (415) 904-2272 or [email protected].
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. Patrick di Battista
(Assistant Director), Melissa Emrey-Arras (Co-Analyst-in-Charge), Marissa
Jones (Co-Analyst-in-Charge), Rachael Chamberlin, Vivian Horn, Jim Lager,
Jean McSween, Karen O'Conor, Dan Schwimer, and Jay Smale also made
significant contributions to this report.

David D. Bellis

Director, Education, Workforce, and Income Security Issues

Appendix II: Advertising Data

To understand how infant formula is advertised through the mass media in
the U.S., GAO purchased and analyzed data from TNS Media Intelligence on
infant formula advertising between 1999 and 2004 in major U.S. markets.
These data identified infant formula advertisements in the following media
outlets:

Television

     o network TV,
     o spot TV,
     o cable TV, and
          * syndicated TV
          * Print
     o magazines,
     o Hispanic magazines,
     o business to business publications,
     o national newspapers,
          * Hispanic newspapers, and  o  other newspapers
          * Radio
     o national spot radio (Data was only available on radio advertising
       expenditures, not the number of ads aired.)

TNS Media Intelligence also searched for infant formula advertisements on
outdoor signs but did not find any during this time period.

To assess the reliability of the data, we talked with company
representatives about data quality control procedures and reviewed
relevant documentation. We determined the data were sufficiently reliable
for the purposes of estimating trends in marketing by formula companies.

                        Appendix III: Literature Review

To identify research that evaluates the impact of infant formula marketing
on breastfeeding rates among the general population and WIC participants
in particular, we searched relevant databases from January 1980 through
July 2005 using Dialog, including Agricola, Biosis, and CAB. We also
consulted with USDA, the Centers for Disease Control and Prevention, the
National WIC Association, infant formula companies, and other experts in
the field. In addition, we identified studies through citations in
previously identified studies, as well as through online journals and
search engines.

In order to focus on evaluation of the impact of infant formula marketing,
we identified studies that met the following criteria:

     o The document is an original research study or an analysis of research
       data evaluating the impact of infant formula marketing on
       breastfeeding rates among U.S. women in general or WIC participants
       specifically.
     o The document has been published in a refereed medium (for example, a
       journal article, book or book chapter, or USDA-issued report).
     o The document's publication date is 1980 or later.
     o All of the research described in the document was conducted in the
       United States.
     o The document is in English.

Some studies were excluded because the research was not conducted in the
United States or because they did not otherwise meet our criteria. For
example, we excluded one study of the impact of hospital discharge packs
on breastfeeding rates because the study had been conducted in Canada.

We identified 17 studies meeting our review criteria, and we conducted
detailed reviews of each study's research methodology, including its
research design, sampling frame, selection of measures, data quality,
limitations, and analytic techniques. 1 We excluded 5 studies due to
methodological limitations and retained 12 for analysis (listed in
appendix IV).

1

The studies used different measures of breastfeeding, such as one week or
one month, and defined exclusive breastfeeding in different ways, ranging
from consumption of nothing but breast milk to consumption of no other
milk or formula.

Page 37 GAO-06-282 Breastfeeding

Eleven of the remaining 12 studies examined the impact on breastfeeding of
giving new mothers free infant formula samples in hospital discharge
packages. 2 Only 2 of these studies included mostly WIC participants. One
study examined the impact on breastfeeding of formula samples distributed
to pregnant women in doctors' offices.

Some studies compared receipt of formula discharge packs to receipt of no
packs, while others compared them to receipt of breastfeeding promotion
packs or other infant supply packs. Two of the studies were supported by
infant formula companies.

                   Appendix IV: Studies in Literature Review

  Studies of Infant Formula Discharge Packs Included in Our Review

Bliss, Mary Campbell, Joy Wilkie, Curt Acredolo, Susan Berman, and
Kathleen Phillips Tebb. "The Effect of Discharge Pack Formula and Breast
Pumps on Breastfeeding Duration and Choice of Infant Feeding Method."
Birth 24:2 (June 1997): 90-97. (This study was supported by infant formula
manufacturer Mead Johnson.)

Caulfield, Laura E., Susan M. Gross, Margaret E. Bentley, Yvonne Bronner,
Lisa Kessler, Joan Jensen, Benita Weathers and David M. Paige. "WIC-Based
Interventions to Promote Breastfeeding Among African-American Women in
Baltimore: Effects on Breastfeeding Initiation and Continuation." Journal
of Human Lactation 14:1 (1998): 15-22. (Study focused exclusively on WIC
participants.)

Dungy, Claibourne I., Mary E. Losch, Daniel Russell, Paul Romitti, and
Lois

B. Dusdieker. "Hospital Infant Formula Discharge Packages: Do They Affect
the Duration of Breast-feeding?" Archives of Pediatrics & Adolescent
Medicine 151 (July 1997): 724-729.

Evans, Cynthia J., Nancy B. Lyons, and Marcia G. Killien. "The Effect of
Infant Formula Samples on Breastfeeding Practice." Journal of Obstetric,
Gynecologic, and Neonatal Nursing (September/October 1986): 401-405.

Feinstein, Joel M., Jay E. Berkelhamer, Mary Ellen Gruszka, Cynthia A.
Wong, and Ann E. Carey. "Factors Related to Early Termination of
Breastfeeding in an Urban Population." Pediatrics 78:2 (August 1986):
210-215.

Frank, Deborah A., Stephen J. Wirtz, James R. Sorenson, and Timothy
Heeren. "Commercial Discharge Packs and Breast-Feeding Counseling: Effects
on Infant-Feeding Practices in a Randomized Trial." Pediatrics

80:6 (December 1987): 845-854.

Neifert, Marianne, Jane Gray, Nancy Gary, and Bonnie Camp. "Effect of Two
Types of Hospital Feeding Gift Packs on Duration of Breast-feeding Among
Adolescent Mothers." Journal of Adolescent Health Care 9:5 (1988):
411-413.

Ryan, Alan S., Jeffrey L. Wysong, Gilbert A. Martinez, and Stephen D.
Simon. "Duration of Breast-feeding Patterns Established in the Hospital."
Clinical Pediatrics 29:2 (February 1990): 99-107. (This study was
conducted by infant formula manufacturer Ross Laboratories.)

Romero-Gwynn, Eunice. "Breast-feeding Pattern Among Indochinese Immigrants
in Northern California." American Journal of Diseases of Children 143
(July 1989): 804-808. (Study included mostly WIC participants.)

Snell, B.J., Marie Krantz, Rebecca Keeton, Karen Delgado, and Carol
Peckham. "The Association of Formula Samples Given at Hospital Discharge
with the Early Duration of Breastfeeding." Journal of Human Lactation 8:2
(1992): 67-72.

Wright, Anne, Sydney Rice, and Susan Wells. "Changing Hospital Practices
to Increase the Duration of Breastfeeding." Pediatrics 97:5 (May 1996):
669-675.

Howard, Cynthia, Fred Howard, Ruth Lawrence, Elena Andresen, Elisabeth
DeBlieck, and Michael Weitzman. "Office Prenatal Formula Infant Formula
Advertising and Its Effect on Breast-Feeding Patterns." Obstetrics &

Gynecology 95:2 (February 2000).

  Advertising Included in Our Review

(130489)

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