This is the accessible text file for GAO report number GAO-06-282 
entitled 'Breastfeeding: Some Strategies Used to Market Infant Formula 
May Discourage Breastfeeding; State Contracts Should Better Protect 
against Misuse of WIC Name' which was released on February 8, 2006. 

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Report to Congressional Addressees: 

United States Government Accountability Office: 

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: 

Appendix I: Briefing Slides: 

Appendix II: Advertising Data: 

Appendix III: Literature Review: 

Appendix IV: Studies in Literature Review: 

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: 

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.[Footnote 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: 

* WIC and non-WIC breastfeeding rates fell short of most national 
goals, but rates were substantially lower for WIC infants. 

* 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. 

* 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 
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 
bellisd@gao.gov. 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. 

Signed by: 

David D. Bellis: 
Director, Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Briefing Slides: 

[See PDF for images] 

[End of slide presentation] 

[End of section] 

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: 

* network TV, 

* spot TV, 

* cable TV, and: 

* syndicated TV: 

Print: 

* magazines, 

* Hispanic magazines, 

* business to business publications, 

* national newspapers, 

* Hispanic newspapers, and: 

* other newspapers: 

Radio: 

* 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. 

[End of section] 

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: 

* 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. 

* The document has been published in a refereed medium (for example, a 
journal article, book or book chapter, or USDA-issued report). 

* The document's publication date is 1980 or later. 

* All of the research described in the document was conducted in the 
United States. 

* 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.[Footnote 2] We excluded 5 studies 
due to methodological limitations and retained 12 for analysis (listed 
in appendix IV). 

Eleven of the remaining 12 studies examined the impact on breastfeeding 
of giving new mothers free infant formula samples in hospital discharge 
packages.[Footnote 3] 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. 

[End of section] 

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 Breast-
feeding 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. 

Study of Prenatal Infant Formula Advertising Included in Our Review: 

Howard, Cynthia, Fred Howard, Ruth Lawrence, Elena Andresen, Elisabeth 
DeBlieck, and Michael Weitzman. "Office Prenatal Formula Advertising 
and Its Effect on Breast-Feeding Patterns." Obstetrics & Gynecology 
95:2 (February 2000). 

FOOTNOTES 

[1] 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. 

[2] 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. 

[3] 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. 

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