New York City's hospitals have banned infant formula from their gift bags for new mothers — a policy that they hope will encourage nursing and healthier babies.
The new policy kicked off during World Breast Feeding Week and calls attention to the increasingly acrimonious debate over the feeding of newborns.
The World Alliance for Breastfeeding Action's Web site states that breast-feeding within the first hour of birth "is the first and most vital step" toward reducing the nation's neonatal mortality rate — one of the highest in the industrialized world.
"Save 1 million babies beginning with one action," the site says.
It is this kind of rhetoric that fuels the great divide between those who choose breast-feeding as a maternal mission and those who opt for bottle-feeding, feeling guilty and inadequate.
In April, the World Health Organization set new international standards, saying that breast-feeding is an "unequaled way of providing ideal food for the healthy growth and development of infants."
Breast-feeding is also deemed healthy for mothers and the American Academy of Pediatrics recommends they breast-feed for six months and preferably one year.
An estimated 70 percent of new mothers start breast-feeding right after childbirth, but by six months, less than 20 percent are still exclusively nursing, according to the 2004 National Immunization Survey.
The rate of breast-feeding increases with education, income and age; black women are less likely to breast-feed, while Hispanics have higher breast-feeding rates.
In New York City's $2 million plan, new mothers will each be given a breast-milk bottle cooler, disposable nursing pads, breast-feeding tips and a baby T-shirt with the slogan, "I Eat at Mom's."
Coaches will work with mothers to begin breast-feeding within the first hour after birth. Mothers will also receive free breast pumps and, for those whose babies remain in the hospital, electric breast pumps.
Formula Undermines Breast-Feeding
Other hospitals across the nation have also stopped giving away formula.
Brigham and Women's Hospital in Boston stopped last year after reviewing extensive data showing formula marketing packs undermined mothers who wished to exclusively breast-feed. Children's Hospital in Philadelphia made the same move.
"The bags imply the hospital's endorsement of branded infant formula, leading formula-feeding families to spend hundreds of dollars more each year on high-priced branded formula," said Alison Stuebe of Brigham and Women's maternity unit.
Sen. Tom Harkin, D-Iowa, has proposed required labeling on cans of infant formula and in advertisements, similar to those on cigarettes.
This spring, a television ad compared bottle-feeding with a pregnant woman straddling a mechanical bull at a bar. "You wouldn't take risks before your baby's born," the advertisement says. "Why start after?"
The breast-feeding campaign is designed to persuade women to make good choices. But for some women, because of personal choice or medical problems, encouragement can feel like pressure.
Assenka Hoffman, a New York City college professor whose son is now 6, can barely talk about her breast-feeding experience without choking up. She had undergone a difficult delivery, losing blood and feeling "completely weakened and exhausted."
When her newborn began losing weight because she was not producing enough milk, the hospital called in a lactation specialist. The aide was not covered by insurance and cost her $800.
A tube was attached to Hoffman's breast to stimulate milk production during nursing and she was required to "pump" in between baby feedings while her son slept.
"It was horrible," said Hoffman. "There was intense pressure to go the natural way and it wasn't working. It had a completely negative impact on the whole experience."
Like other new mothers, Hoffman had eagerly decided to breast-feed, but hadn't "given it a lot of thought in terms of how it would actually work."
"I suddenly went from this thing that was supposed to happen naturally to a complicated process," she said. "I did not have a moment when my body wasn't being used for something except for sleeping and pumping and sterilizing bottles."
Scientific evidence shows that breast-fed babies are less vulnerable to acute infectious diseases and allergies. Some studies also suggest that they are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma, according to the American Academy of Pediatrics.
Research on premature babies has even found that those given breast milk scored higher on IQ tests than those who were bottle-fed.
At the University of California's San Diego Medical Center, the nursing staff is respectful of mothers who choose not to breast-feed for a variety of reasons, including a traumatizing pregnancy or plans for adoption.
But others, after hearing the benefits of nursing, change their minds, said Corey Anaka, a nurse and lactation specialist.
"We have a reasonable approach," said Anaka. "The whole essence is to teach mothers and to give correct information so they can make a conscious choice."
The hospital was just designated one of only 56 "baby-friendly" hospitals in the United States by the WHO. It has refused all free formula since 1997 — only for its gift bags, but hospitalwide. This and other pro-lactation policies have seen the breast-feeding rates at discharge reach 90 percent.
"The staff is awesome," said Cheri Wolf, who delivered a healthy boy by Caesarean section July 26 and began breast-feeding two hours later. "I even get the impression that if I ask the janitor a question about lactation he'd be able to tell me."
The 38-year-old single mother had hoped to breast-feed but was nervous that she, like other friends, would not be successful. But, an education program through the Red Cross that provides food vouchers to low-income women and a class sponsored by the hospital persuaded her to give it a try.
The state's Women, Infant and Children program also provides another incentive if women continue breast-feeding — it provides increased food allowances.
'A New Baby, Not a Cow'
"We in the world of lactation consider human milk to be medicine," said Anaka. "Formula is like a foreign protein. This is a new baby, not a cow."
But critics say withholding formula puts low-income women at a disadvantage.
Jennifer Shu, an Atlanta pediatrician and author of "Heading Home With Your Newborn," said most babies will eventually get formula by the end of their first year.
Offering free samples can help families save money or just use certain formulas on a trial basis until they find a "good fit" for their baby.
"It's great that the breast-feeding rates have gone up," said Shu, "but it's hard to know whether that improvement was because of the new policy or because the staff is now spending more time educating new moms about the benefits of breast-feeding."
An 'Excellent Alternative'
For those who cannot breast-feed for medical or other reasons, formula is an "excellent alternative," she said.
"Low-income families who choose formula but are unable to afford it may end up feeding their babies unhealthy alternatives, such as water, juice or cow's milk," said Shu. "Having free samples available until these families can get on WIC [the Women, Infant and Children program] or otherwise find the finances for formula can save infant lives."
New York's Health and Hospitals Corp. said it would continue to make formula available for women who request it or are unable to breast-feed for medical reasons. Only 24 percent of the city's babies are discharged exclusively breast-feeding.
"From my perspective, that's a bogus argument," said Alan D. Aviles, head of the city's Health and Hospitals Corp., to The New York Times. "The reality is that there's nothing cheaper than feeding a child breast milk."
But in a society that provides little support for breast-feeding, the issue takes on larger political ramifications, according to Kim Gandy, president of the National Organization for Women.
"There is no question that breast-feeding is better for babies and actually has some benefits for mother as well, but we as a society make it very difficult — and removing free formula coupons from [a] postbirth swag bag doesn't address those barriers," said Gandy.
"It sends a good message, but it doesn't make other options easier or possible for women," she said.
Most companies still only grant women 12 weeks maternity leave — barely enough time for mother and baby to bond or to establish a good nursing regimen, according to Gandy.
More than 60 percent of mothers of young children work. Only a third of large companies provide a private, secure area where women can express breast milk during the workday and only 7 percent offer on-site or near-site child care, according to a 2005 national study of employers by the nonprofit Families and Work Institute.
"We are saying you're a bad mom if you don't breast-feed, but we are going to make it impossible for you," she said. "It's a big guilt trip with nothing at the end."
The debate rages on and mothers are caught in the middle.
Freelance writer Ronda Kaysen just gave birth to her first child in Mexico and has been fighting a different kind of social attitude.
"Here they pressure you to formula feed," said Kaysen. "Wealthy women bottle-feed and poor women breast-feed. My friend who is a college professor and plans to have children is horrified I am breast-feeding."
Kaysen struggled to prevent the Mexican maternity ward nurses from giving her baby boy sugar water or bottle formula. She even switched obstetricians to find one who would support her decision to breast-feed.
Still, she understands the complexity of the choice women have to make.
"I think it is a personal decision," said Kaysen. "To me it seems like the easiest thing to do. Bottle-feeding just seems like so much more work."