As the state's policy makers debate whether to ban maternity ward gift bags, a growing number of Massachusetts hospitals are quietly doing away with the formula-filled freebies on their own.
The state's busiest baby unit, at Brigham and Women's Hospital, banished gift bags provided by infant formula companies on Feb. 1. Last week, Cambridge Health Alliance replaced them with bags emblazoned with the alliance's logo -- but without formula. And administrators at Beth Israel Deaconess Medical Center, where 5,000 babies are born each year, intend to eliminate the sample and coupon giveaways by the summer.
The hospitals' action represents a confluence of trends sweeping the healthcare industry. After being stung by revelations showing doctors indulging in expensive meals, gifts, and trips paid for by pharmaceutical companies, hospitals are eager to project a different image.
And with hundreds of medical studies demonstrating the benefits of breast-feeding -- for both babies and their mothers -- maternal and infant health specialists who preach the importance of nursing said they had become deeply uncomfortable about showering women with bags touting formula. A scientific analysis in 2000 of previously published studies found that women who got gift bags were less likely to exclusively breast-feed.
''The message to the mom when she receives the discharge bag is, 'While we're supporting breast-feeding, we also believe formula feeding is OK,' " said Carol Downes, nursing director for maternal newborn services at Melrose-Wakefield Hospital, which recently stopped distributing infant formula gift bags. ''We want the message to be clear and not confused."
The decision by at least five hospitals to remove the bags in the past few months emerges as the Massachusetts Department of Public Health considers whether to impose a mandatory ban on formula bags, which have been a major thrust of marketing campaigns by pharmaceutical companies for decades.
A spokeswoman for Mead Johnson Co., which makes the baby formula Enfamil, said the company would respect the wishes of hospitals that don't want gift bags. But it will continue to educate physicians about options for infant feeding.
In a statement, the formula industry trade association lamented the decision by hospitals to reject the bags.
''Mothers should be allowed full access to all available information on infant feeding options and practices, as well as discharge gift bags including samples, which can assist in informed infant feeding decisions," the International Formula Council said.
The gifts date to an era when formula feeding had a seductive cachet, promising convenience and even a sense of propriety for families. The makers of infant formula established a lucrative route directly to new mothers -- via hospital maternity wards.
In a state such as Massachusetts, that gave the companies access each year to tens of thousands of new mothers, who, if they fed their babies formula, could expect to spend $1,000 to $3,000 annually depending on the type used.
''I've been a nurse for 27 years," said Charlene Torrisi, director of maternal-newborn services at North Shore Medical Center in Salem, ''and we've been giving these bags the whole time."
The pouches, now typically handsome black bags with multiple pockets, contain an array of items for moms and babies: information about breast-feeding, pens, wipes -- and bottles of premixed formula, formula powder, and coupons for formula. Most often, the bags are supplied by the makers of two leading product lines, Similac and Enfamil.
A decade ago, Boston Medical Center and Massachusetts General Hospital decided not to accept freebies from formula companies, but most maternity wards in the state kept taking them.
Still, in the past 10 years, scientific evidence strengthened the argument in favor of breast-feeding, with studies suggesting that babies who are nursed are less prone to stomach ailments and earaches, and that breast-feeding may even protect against chronic conditions such as diabetes and obesity. One study even found that children were more likely to see their first birthday if they were breast-fed.
''People say nobody dies because they weren't breast-fed," said Dr. Lawrence M. Gartner, retired chief of obstetrics at University of Chicago. ''It's not true. Not only do babies get sick because they weren't breast-fed, they die."
Major associations of medical specialists, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, have recommended that babies be breast-fed exclusively for at least the first six months of their lives.
With the weight of that medical advice firmly behind them, administrators at the Massachusetts Department of Public Health last year sought to become the first state to ban gift bags. The state Public Health Council adopted the prohibition in December, but Governor Mitt Romney asked the panel to repeal the ban, saying women should be free to choose whether they want a gift of formula.
In February, the Public Health Council followed the governor's wishes -- but also ordered administrators of the Department of Public Health to spend an additional three months reviewing the ban and to report back May 23.
Romney spokesman Eric Fehrnstrom said that the governor remains committed to assuring women have a right to a gift bag if they want one.
''It's very interesting," Fehrnstrom said. ''Pharmaceutical companies and medical device makers market their products to hospitals, and everything from doctor's stationery to the vending machine in the lobby bear a corporate insignia.
''No one is seeking to end those practices, and yet there is a very vocal minority of breast-feeding advocates who want to take a punitive approach with mothers who choose formula."
But advocates of a ban say that even though several major hospitals have now given up the bags, government action is necessary.
''While we are pleased to see change happening in this direction, I am quite sure this marketing practice will persist in much of the state if there is not a regulation," said Dr. Melissa Bartick, chairwoman of the Massachusetts Breastfeeding Coalition.
When hospitals opt to abandon the company-provided bags, they often decide instead to give bags trumpeting the hospital, with water bottles, T-shirts, and other items -- but no formula.
That's what Cambridge Health Alliance is doing, and at Beth Israel Deaconess ''we might as well market the hospital rather than the formula," said Dr. Kim Lee, associate director of the newborn nursery. Lowell General Hospital is the fifth hospital to recently eliminate the bags.
Not all hospitals are prohibiting the bags. Administrators at several hospitals serving low-income patients said they intend to continue distributing the formula-laden gifts, unless the state orders them to stop.
Studies have shown that poor women are less inclined to breast-feed than wealthier women.
''They're the ones going back to work sooner," said Gail Walker, director of maternal-child health at Lawrence General Hospital, which still provides the bags. ''Not everyone has a job that lets you take three months off for maternity leave. If you don't have adequate facilities to pump appropriately and then store it, then you're just not going to do it."
At UMass Memorial Medical Center in Worcester, the people who run the maternity center eliminated the bags about a year ago. But they're back now.
''Patients were angry -- it came back in our patient satisfaction surveys," said Kathy Teeple, director of Women and Children's Services at UMass Memorial. ''A lot of patients see that as their right, and it's expected when they come in that they're going to get that."
Stephen Smith can be reached at firstname.lastname@example.org.