Analyzing the Effect of the 2022 Formula Shortage on Postpartum Parents' Feeding Decisions in an Urban Hospital Setting

Introduction

The baby formula shortage of 2022 was a topic of national discussion and perpetuated significant fear among new parents at its height. According to the New York Times, pandemic-related supply-chain issues and ingredient shortages led to some formulas being out of stock around the country. The problem compounded in February 2022, when Abbott, one of the four major formula manufacturers in the United States, voluntarily recalled a number of its products, including the popular Similac formulas, due to possible contamination with Cronobacter sakazakii. Parents were faced with bare shelves or purchase limits, as well as weeks-long delivery estimates on online purchases. Data suggest that formula inventory was down by up to 40% nationwide. ¹

A previous study conducted in Sichuan Province, China, explored the opinions of mothers on formula feeding after a melamine scandal in 2015, ² and other prior articles have offered advice and recommendations on how to adapt to the 2022 formula shortage.^3,4 However, there is currently a lack of data assessing the relationship between the formula shortage and new parents' feeding decisions. This study aimed to investigate how the feeding decisions of new parents in St. Louis, Missouri, were affected by the 2022 formula shortage, in comparison to demographic factors and habits with previous children.

Our study compared parents' feeding decisions for their new baby to those for their previous children in an effort to understand whether any changes in their decisions could be attributed to the shortage. The project explored these decisions (breastfeeding, formula feeding, or a combination) during parents' postpartum hospital stay via a survey designed to assess their demographic information, financial/social support system, reasons for feedings decisions with previous children, reasons for current feeding decisions, and how influential the formula shortage was on these decisions. We hypothesized that moms may be inclined to either exclusively breastfeed their new baby when they did not do so previously, or to breastfeed their new baby more frequently than they did with previous children due to the formula shortage.

Materials and Methods

Approval for this study was obtained from both the Saint Louis University Institutional Review Board (IRB) and the Sisters of St. Mary (SSM) Health Research Compliance and Research Business Review (RBR). One hundred participants were selected from the postpartum patient list at St. Mary's Hospital, an urban health center in St. Louis, Missouri, to participate in the study. During the study month (January 16–February 10, 2023), there were 171 singleton deliveries and 6 twin deliveries at St. Mary's hospital, forming a total of 177 new parents available to survey. Of those, ∼120 were approached, ∼20 declined to participate (the number who declined was not precisely recorded), 1 began but did not fully complete the survey, and 99 fully completed the survey (see Fig. 1 for a flow sheet of this information).

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FIG. 1.

Number of patients recruited to and included in the study over the 1-month data collection period.

The health and well-being of both the parents and babies were taken into consideration before they were approached to participate in the study. At the beginning of each data collection session, a member of the study team first conducted a chart review on the parent's and baby's charts to ensure that they were not suffering from any major birth-related complications. Exclusion criteria included any parents who were febrile, hemodynamically unstable, or recovering from traumatic deliveries. Parents in the intensive care unit (ICU) were excluded, and only those on the floor were approached. Similarly, though parents whose babies were in the neonatal ICU were recruited, we did not approach anyone whose baby was unstable or declining. Postpartum parents of all ages, gender identities, and ethnic backgrounds were included in the study, and if the participant did not speak English, a trained medical interpreter was used for their survey administration.

Parents were approached in-person at their bedside by a member of the study team during their postpartum hospital stay and asked whether or not they would like to participate in the 5-minute survey. They were told that the survey was completely optional and that no protected health information would be collected. There was no incentive for taking the survey. If they were willing to participate, they were administered a 15-question Qualtrics survey on an institution-owned laptop through which they could either fill out the questions themselves or have a study member read the questions to them and fill out their responses on their behalf, depending on preference. If guests were present, patients were offered the option of privacy during the survey administration.

While taking the survey, patients were required to answer all of the questions, but many questions contained the response option “prefer not to answer,” allowing patients to remain as private with their information as they chose. The study team member was present for the duration of the survey period to assist with the process. Once patients were discharged, they were no longer eligible to participate. Once the survey was complete, that participant's data collection was concluded; there was no further follow-up. All data collection was done over a 1-month period, 4 months after the conclusion of the formula shortage (January 16–February 10, 2023).

Survey data were then sent to the Advanced Health Data (AHEAD) Research Institute at Saint Louis University and analyzed by a biostatistician utilizing chi-square and Fisher's exact tests. Ninety-nine patients were included in data analysis due to one participant not completing the survey. Independent variables included age (less than 23, 23–27, 28–32, or greater than 32), race (white or African American), number of previous children (0, 1, 2, or 3 or more), feeding decision for previous children (exclusively breastfed, exclusively formula fed, or combination of breast- and formula feeding), prior knowledge of formula shortage (yes or no), influence of formula shortage on feeding decision (not influential, mildly influential, neutral, somewhat influential, or very influential), income (less than $25,000, $25,000–$44,999, $45,000–$85,000, greater than $85,000, or prefer not to answer), and social support (low, medium, or high).

Social support was calculated based on the number of boxes checked under the “Who do you receive social support from?” question. The options included spouse, parent(s), other relative(s), friend(s), licensed therapist or clinical psychologist, religious community, other, and not applicable. Checking one box qualified as low support, two to three boxes qualified as medium support, and four to six boxes qualified as high support. When these variables were analyzed against feeding decisions for the new baby (combination of breast- and formula feeding, exclusively breastfeeding, or exclusively formula feeding), p-values were generated for each variable. Alpha was set at 0.05.

Results

There was a significant relationship between feeding decisions for the new baby and feeding decisions for previous children (p < 0.0001), indicating that parents are significantly influenced by their feeding decisions for previous children when making decisions for their new baby. There was also a significant difference between a combination of breast- and formula feeding versus exclusively breastfeeding for parents over the age of 32 (p = 0.04), suggesting that in this population, women over the age of 32 were more likely to do combination feeding rather than exclusively breastfeeding. Further, there was a significant difference between choosing a combination of breast- and formula feeding versus exclusively breastfeeding for white parents (p = 0.03), showing that white parents were more likely to exclusively breastfeed than to combination feed. In addition, there was a significant relationship between 0 previous children and exclusively breastfeeding versus exclusively formula feeding (p = 0.02), demonstrating that parents with no previous children were more likely to exclusively breastfeed than to exclusively formula feed in the immediate postpartum period.

There was no significant association between feeding decisions for the new baby and mother's age, race, number of previous children, prior knowledge of the formula shortage, perceived influence of the formula shortage on feeding decision, income, or degree of social support. There was also no significant association between exclusively breastfeeding versus a combination of breast- and formula feeding and age less than 32, race, number of previous children, prior knowledge of the formula shortage, perceived influence of the formula shortage on feeding decisions, giving previous children a combination of breast- and formula feeding, or income. Moreover, between exclusively formula feeding versus exclusively breastfeeding and the following variables, there was no significant relationship: age, race, two previous children, three or more previous children, prior knowledge of the formula shortage, perceived influence of the formula shortage on feeding decisions, and income (see Table 1).

Discussion

Though the formula shortage seemingly caused nationwide worry and uncertainty among new parents, the issues it posed were perhaps not influential enough to change parents' feeding decisions. Our study demonstrates that feeding methods with previous children were more contributory to parents' feeding decisions with their new babies than a 40% depletion in the United States formula supply. This suggests that feeding experiences with previous children (both positive and negative) likely influenced current feeding decisions, though this was not directly studied. It is possible that prior breastfeeding struggles discouraged parents from attempting to breastfeed again. Further research may be necessary to explore this phenomenon. Additionally, most women chose to breastfeed if they breastfed previous children, and most women planned to breastfeed their first baby. This highlights the importance of prenatal and postnatal lactation support for new parents as well as the notion that this support for a parent's first child is especially crucial and may lead to better health outcomes for both the parent and for subsequent children.

The relationship that we found between older age and a combination of breast- and formula feeding contradicts previous literature which demonstrates a pattern between older parents and exclusive breastfeeding due to potential socioeconomic and developmental advantages. ⁵ Instead, our finding may provide further evidence that parents' feeding decisions are influenced by past difficulties. Since older parents are more likely to have had previous children, they are also more likely to be influenced by their decisions with previous children and discouraged by previous breastfeeding challenges.

The racial discrepancy our study elucidated in exclusive breastfeeding between white and African American parents may shed further light on previously examined disparities. According to prior literature, certain barriers are disproportionately experienced by Black women, including earlier return to work, inadequate receipt of breastfeeding information from providers, and lack of access to professional breastfeeding support. ⁶ This suggests that to increase the rate of breastfeeding among Black infants, further studies should explore possible interventions to address these barriers and mitigate the disparity.

A limitation of our study includes the relatively small sample size (n = 99) as well as the administration of these surveys to patients at only one hospital in one city in the United States. Further, data were collected within a narrow window (∼1–2 days postpartum), after which feeding decisions may have changed. It is also worth noting that the time at which these surveys were administered (∼4 months after the shortage had largely resolved) may have affected parents' responses. If our study was conducted during the peak of the shortage, results may have been different.

Conclusion

In summary, the results of this study indicate that when making feeding decisions for their new baby, parents are significantly influenced by the feeding decisions for their previous children but are not significantly influenced by the 2022 formula shortage, contrary to the authors' hypothesis. Parents were more likely to exclusively breastfeed their new baby if they exclusively breastfed previous children. They were also more likely to exclusively formula feed their new baby if they did a combination of breastfeeding and formula feeding with previous children. Parents were more likely to exclusively breastfeed than exclusively formula feed if the new baby was their first child. Parents over the age of 32 were more likely to employ a combination of breast- and formula feeding than to exclusively breastfeed. White parents were more likely to exclusively breastfeed than to do a combination of breast- and formula feeding.