NYC breastfeeding: a new-old plan to wean the world off formula

Remember the Nestlé formula boycott? The long-term global effort to encourage breastfeeding as a healthier choice for newborns than formula – once focused on developing nations – is now a trend among US hospitals. But a new program to decrease the use of formula in hospitals, backed by NYC Mayor Michael Bloomberg, is being criticized as meddling in the decisions of mothers.

Elise Amendola/AP
Nurses walk under dimmed lighting during "quiet time" at the Newborn Family Unit at the Massachusetts General Hospital in Boston. Massachusetts was the second state where hospitals banned giving away formula to new mothers.

The collective howl of “nanny state” that met New York City Mayor Michael Bloomberg’s new “Latch On NYC” program, aimed at encouraging breastfeeding over formula, seems to have overshadowed the fact that the program is part of a well-established trend supported by medial associations, the World Health Organization (WHO), and the United Nations.

The trend has echoes of the concerns behind the Nestlé formula boycott of the 1970s and 1980s in the US and Europe. That campaign contended that the Swiss company’s promotion of infant formula over breast milk was unhealthy, particularly in less developed nations where unsanitary conditions and nutritional deficiencies made formula a poor substitute.
New York’s move against automatically giving away free formula to new moms at hospitals is seen as a way to increase the incentive to breastfeed. It follows Rhode Island, which last year became the first state where birthing centers and hospitals voluntarily banned giving formula to new mothers in favor of educating them on the benefits of nursing. Massachusetts followed suit in July, with all 49 birth facilities voluntarily deciding to stop handing out free formula. 

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In 2005, the Massachusetts Public Health Council instituted a statewide ban on giving out free formula, but then-Gov. Mitt Romney overturned the decision a few months later. 
There are currently 600 hospitals in the US that have banned the free new-mommy swag bags given at discharge from the hospital – discharge bags full of everything from formula to diapers and other baby gear. Also, hospitals can receive a "baby friendly” accreditation, which was developed by WHO and UNICEF in 1991 and is administered in the US by Baby-Friendly USA.

There is not yet enough evidence to track the direct impact of these bans, says Marsha Walker, executive director of the National Alliance for Breastfeeding Advocacy (NABA), who was involved in the legislative advocacy for the Massachusetts Breastfeeding Coalition. But she adds that there is an increased interest in hospitals providing lactation care services.
New York's first “baby friendly” hospital – Harlem Hospital – was where city officials announced the launch of the "Latch On NYC" program May 9. The initiative is aimed primarily at mothers who choose to breastfeed and helping them “to increase breastfeeding exclusivity and duration,” according to the Department of Health description. 
Public health officials are calling on all New York hospitals to voluntarily commit to the initiative, which asks the institutions to enforce the New York State hospital regulation, effective since 2005, that breastfeeding infants not be given formula feedings unless by “a specific order by the attending practitioner or at the request of the mother.” The initiative also involves restricting nurses’ access to formula and developing a better tracking system for formula distribution. Hospitals will also agree to discontinue the distribution of free or promotional infant formula as well as prohibit displaying of formula promotional materials. 
Hospitals run by New York’s Health and Hospital Corporation had already started banning gift bags and formula promotional materials in 2007. The current “Latch On NYC” campaign continues that trend as New York tries to increase exclusive breastfeeding for infants up to six months of age. Ninety-three percent of births in the city are at hospitals where breastfed infants are also given supplemental formula, according to the Department of Health.

Bloomberg says mothers should choose what is right for them. The program guarantees they will be able to make that decision free from corporate influence. But many mommy bloggers and pundits have criticized the program as a new round of over-reach into personal choice by Bloomberg public health policy. The city is still reeling from his proposal this spring to ban supersize sodas in the city. 
Starting in September, more than half of New York’s maternity hospitals (27 of 40) will ask mothers of newborns to listen to talks about why breast milk is more healthy than formula samples that hospitals traditionally have offered free of charge.
“Restricting access to samples and information from formula manufacturers is not the answer to increasing breastfeeding rates,” said Mardi Mountford, the executive vice president for the International Formula Council (IFC), in a written statement. The IFC is an association of manufacturers including Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition Perrigo Nutritionals, and Pfizer Nutrition.
“A way to help mothers is to be supportive of the feeding choice they make for their infants regardless if they choose breastfeeding, formula feeding or a combination of both,” said Ms. Mountford. “For infants who are not breast fed, infant formula is the only safe, nutritious and recommended feeding option. Clinical studies and many years of consumer use have shown infant formula to be a safe alternative which supports normal growth and development in infants.”

Campaigns aimed at increasing breastfeeding rates, Mountford said, should include advice and support for new mothers, including education on proper formula preparation and bottle-feeding techniques so that mothers will be fully prepared for whichever option they choose.
Ms. Walker says the criticism of Bloomberg’s plan has misconstrued the purpose of the program, which is designed to put best practices into place for health-care providers who give counseling and evidenced-based advice on breastfeeding, and not to tell mothers what to do. 
“It has nothing to do with how choices are made or whether or not a woman chooses to breastfeed,” says Walker. “The initiative assures that if a breastfed baby needs to be supplemented with formula, it is not because the nurses don’t have time or because mothers don’t know how to breastfeed.”
There may be medical reasons that mothers would need to use formula for newborns, says Walker, but those are rare. 
Walker, who is also a certified lactation consultant, says that one of the main reasons women ask for formula from hospitals is because they are having trouble breastfeeding. The role of the hospital and health-care providers, says Walker, is to find out why a new mother is having trouble and how they can support her and the baby.
“The decision to breastfeed or not is made while moms are pregnant and well before they get to the hospital,” says Walker.
That decision may be influenced by formula marketing such as "discharge bags," suggests a recent study in the Journal of Human Lactation, titled “Removal of Industry-Sponsored Formula Sample Packs from the Hospital: Does It Make a Difference?” 
The study found that women who receive industry-sponsored formula when they are discharged from the hospital are less likely to breastfeed exclusively for the first six months, as recommended by the American Academy of Pediatrics. And data from the Centers for Disease Control and Prevention (CDC) show that only 13 percent of infants nationwide meet that goal.
Seventy-two percent of US hospitals gave mothers formula samples when they were discharged in 2010, a decrease from 91 percent in 2007, according to the study, conducted by staff at the Cooper University Hospital in Camden, N.J., and Boston Medical Center.
The IFC refutes research that links formula samples to decreased breastfeeding. 
“Results of research into any relationship between infant formula hospital sample distribution and breastfeeding have been inconsistent; some studies show an association while others do not,” says the IFC on their website.
Breastfeeding rates are on the rise nationwide, according to CDC data tracking breastfeeding from 2000 to 2009. The initiation rate increased from 71 percent in 2000 to 77 percent in 2009. Also breastfeeding at six months increased from 34.2 percent to 47.2 percent. The US Department of Health and Human Services’s goal is 60 percent by 2020, according to its Healthy People 2020 objectives.
Giving mothers free samples of formula is a marketing strategy that violates the World Health Organization’s International Code for Marketing Breast-Milk Substitutes, which was first published in 1981 to emphasize the influence of manufactured substitutes on breastfeeding practices. 
“It’s a very effective marketing strategy,” says Walker. “It’s not a gift, it’s not charity, and it's not because the hospital feels it is good for mothers.”
Formula companies know that 95 percent of mothers will use the formula brand that they receive from the hospital, says Walker, because mothers think that if the hospital hands it to them, doctors endorse it.
The American Association of Family Physician’s (AAFP) website, recommends that hospital staff not give formula or pacifiers to babies whose mothers choose to breastfeed exclusively. The organization also “discourages distribution of formula or coupons for free or discounted formula in hospital discharge or physician office packets given to mothers who choose to breastfeed exclusively.”
The American Academy of Pediatrics board of directors also passed a resolution in July to “advise pediatricians not to provide formula company gift bags, coupons, and industry-authored handouts to the parents of newborns and infants in office and clinic settings,” also stating that infant formula marketing has “direct negative effects on the continuation and exclusivity of breastfeeding.”
US Surgeon General Regina Benjamin supports a mother’s right to choose, but also says that mothers need access to accurate information about breastfeeding.
“The decision to breastfeed is a personal one, and a mother should not be made to feel guilty if she cannot or chooses not to breastfeed,” Dr. Benjamin said in a statement last year for World Breastfeeding Week, which runs Aug. 1 to 7. “But given the importance of breastfeeding for the health and well-being of mothers and children, we need to do what we can to help mothers who want to breastfeed to do so successfully.”

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