Although a few books have gamely tackled the topic, claims that the infant formula industry has actively and deliberately thwarted breastfeeding are often shrugged off as being overblown and, perhaps, paranoid. Programs to increase breastfeeding rates are dismissed as being unnecessary folly.

Well, Deborah L. Kaplan and Kristina M. Graff are here to say otherwise. In a recent article for the Journal of Urban Health, they succinctly review the history of infant formula marketing in the U.S., present evidence-based studies that show the impact of such marketing practices, and detail New York City’s exciting new effort to counteract such marketing and promote breastfeeding.

For the history and the impact, I urge you to track down the full-text of Kaplan and Graff’s article. It is a quick and enlightening read. (Hint: Your local librarian should be able to request it through inter-library loan.) Here, I wish to focus on New York City’s commendable, concerted effort to address the problem.

The Big Apple’s Problem
Compared with the 2004 national rate of 73.8% of mothers initiating breastfeeding, the 84.3% initiation rate reported here looks pretty good. The picture changes quickly. Although only 30.5% of U.S. women were exclusively breastfeeding at three months, exclusive breastfeeding in the Big Apple dropped off more and sooner: Just 21.4% were exclusively breastfeeding at three months.

That’s a far cry from the Healthy People 2010 breastfeeding goals of 50% exclusive breastfeeding at three months and 25% exclusive breastfeeding at 6 months!

The Big Apple’s Solution
As a starting point for its pro-breastfeeding plan, New York City Department of Health and Mental Hygiene (DOHMH) looked at what has worked for the infant formula industry, namely “strategic marketing, targeting women with direct advertising and with the implicit and explicit endorsement of health providers.” (Kaplan and Graff point specifically to the industry’s efforts to reach women during the prenatal period, use of non-medically indicated formula-feeding at the hospital, and the distribution of formula gift bags at hospital discharge as being important weapons in the formula industry’s marketing arsenal.)

The aim of New York City’s pro-breastfeeding plan is “to increase rates of exclusive breastfeeding and prolong breastfeeding duration and ultimately make breastfeeding the feeding method of choice.” In other words, the overriding goal is to “make breastfeeding a normative, expected and supported behavior” by:

• raising awareness
• providing local resources and support
• changing systems that interfere with pregnant and parenting women and their families
• advocating for policy changes to support breastfeeding, especially for low-income and working women
  

The city’s strategy acts on three levels:

• Individual level includes breastfeeding promotion directed at providers and client/family education. Examples: Certified Lactation Coordinator (CLC) training provided for 250 public health and hospital workers by the end of 2008; Grand Rounds and other educational events and publications provided for health care providers citywide; enhanced breastfeeding support component added to newborn home visit programs.
  

• Institutional/community efforts target communities, hospitals and workplaces. Examples: Development and distribution of free multimedia breastfeeding education materials; financial support and technical assistance for a two-year baby-friendly/breastfeeding friendly hospital initiative in the 11 public hospitals of NYC’s Health and Hospitals Corportation (HHC); DOHMH’s recently developed breastfeeding-supportive workplace policies and opened a lactation room and a breast pump loan program to serve as a model for other NYC businesses.
  

• Policy level efforts address local, state and federal policies. Examples: DOHMH has provided input and advocacy for several bills that would support breastfeeding and improve maternal, child, and nutritional services.

Lessons Learned
Breastfeeding advocates hoping to replicate NYC’s strategy elsewhere should pay close attention to the lessons learned, specifically:

• Resources matter. A successful effort requires money, staff, and technical assistance.

• Partnerships help. Combined efforts by public agencies and hospitals are best.

• Strong leaders are needed. “Champions” of breastfeeding efforts can model that it is a high priority, set high expectations for change, and encourage others to buy in to the new practices.

• Clear objectives—and accountability—are must-haves. Perhaps measures can be incorporated in electronic information systems or performance evaluations; this can make it easier to confirm that change has occurred.

• Incentives help. Emphasis on how the changes benefit staff and institution are important. Health care providers have a full workload as-is; they will be more accepting of changes that will lessen their load.

• Strong messages are essential. Public and vocal resistance can be expected from the infant formula industry and its stakeholders, so a pro-breastfeeding strategy must be prepared to respond with “a clear rationale” and “ample success stories.” All public and private pro-breastfeeding parties involved in the effort should be on-board with the response.

• Policies matter. Workplace, community, city, state and even federal policies that recognize the role of breastfeeding in maternal-child health are important for sustaining breastfeeding efforts.
  

Frank Sinatra famously sang of New York “If I can make it there, I’ll make it anywhere.” I can’t say if the aphorism is true in all cases, but I sure do hope that it’s true in this case of the city’s breastfeeding support plan: I hope it succeeds in New York and spreads to the rest of the country!