Making Breastfeeding the Norm in New York City

Breastfeeding, in particular exclusive breastfeeding for at least 6 months, has been proven to provide multiple short- and long-term health benefits for mothers and infants. While 84% of New York City (NYC) mothers initiate breastfeeding, over half stop exclusively breastfeeding in less than 1 week, and only about one in three women breastfeed exclusively for 8 or more weeks. There are also substantial disparities in the percentages of NYC women exclusively breastfeeding at 2 months by race, ethnicity, and education: 33% of women with a college degree compared to 25% of women with less than a high school degree and 19% non-Hispanic black compared to 34% non-Hispanic white and 26% Hispanic or Latina women (unpublished raw data, 2004–2005, from the Pregnancy Risk Assessment Monitoring System [PRAMS], NYC Department of Health and Mental Hygiene [DOHMH] Bureau of Maternal, Infant, and Reproductive Health). When NYC mothers ¹ who initiated breastfeeding were asked why they discontinued, the three most common reasons given were not producing enough milk (39%), breastmilk didn't satisfy the baby (38%), and the baby had difficulty breastfeeding (24%) (unpublished raw data, 2006, from PRAMS, NYC DOHMH Bureau of Maternal, Infant, and Reproductive Health). These are all factors that can be prevented if women are provided with appropriate breastfeeding education and support during pregnancy, while at the hospital, and when they return home after hospital discharge. When asked about hospital practices to support breastfeeding, only 37% of mothers who initiated breastfeeding at the hospital said they were shown how to breastfeed, 42% did not have their babies room-in with them, 69% did not initiate breastfeeding within 1 hour of giving birth, 78% of their babies were given liquids besides breastmilk, and 86% were given a gift pack with formula (unpublished raw data, 2004–2005, from PRAMS, NYC DOHMH Bureau of Maternal, Infant, and Reproductive Health). All of these factors are proven influences on mothers' breastfeeding practices.

To make breastfeeding the norm, it is necessary to tackle breastfeeding barriers and provide adequate resources at the individual, institutional, community, and policy levels. The NYC DOHMH has implemented a citywide multilevel strategy “to make breastfeeding a normative, expected, and supported behavior by raising awareness, providing local resources and support, changing systems that interface with pregnant and parenting women and their families, and advocating for policy changes that support breastfeeding, especially for working and low-income women who face the greatest barriers.” ¹ DOHMH's strategy has three areas of focus: (1) individual-level change, (2) institutional- and community-level change, and (3) policy change.

At the individual level, breastfeeding is promoted through home visiting programs that target women and families in communities with the lowest breastfeeding rates. The Nurse-Family Partnership (NFP), a national evidence-based program in which nurses conduct home visits to first-time mothers from pregnancy until their child is 2 years old, was implemented by DOHMH in NYC in 2003 and is now the largest urban NFP site in the country, with over 2,200 active participants. NYC NFP nurses are all Certified Lactation Counselors and provide ongoing encouragement, hands-on support, and breast pumps to the mothers they serve. The Newborn Home Visiting Program, in which paraprofessionals conduct a home visit to all newborns in three low-income areas (over 8,000 visits per year), promotes breastfeeding and links women to breastfeeding support services. Provider education is offered through Certified Lactation Counselor training for hospital- and community-based providers, training over 200 staff each year. Through the DOHMH Public Health Detailing program, a program modeled on pharmaceutical marketing to providers, public health educators “sell” public health on select topics. During a citywide Public Health Detailing breastfeeding campaign, educators visited providers in all 42 NYC hospitals with maternity services to provide up-to-date recommendations and educational materials for providers and patients, stressing the key role of providers in influencing women's infant feeding decisions.

At the institutional and community levels, the DOHMH is working intensively with hospitals to make systems changes to support breastfeeding and ultimately become Baby-Friendly Hospitals. We recently received Communities Putting Prevention to Work funding through the Centers for Disease Control and Prevention to increase this effort to an additional 13 hospitals and have aligned our work with efforts by the New York State Department of Health, which also received Communities Putting Prevention to Work funding. The DOHMH also implemented the first workplace lactation room and breast pump loaner program in a NYC government agency, and we have promoted this model to other government agencies.

The DOHMH has developed a policy agenda and is working with local and state partners to support legislation and regulations that promote breastfeeding and reduce the influence of the infant formula industry by restricting their ability to market infant formula.

We have changed the conversation about breastfeeding in NYC and have made important strides towards shifting the norm on infant feeding practices. What remains clear, despite our successes, is that in addition to continued work with individuals and hospitals, there is much to be done at the community and policy levels to succeed in making breastfeeding the norm. At the community level, even when women return home following hospital discharge determined to exclusively breastfeed, they often encounter obstacles including lack of support or even discouragement from family members, limited access to resources to help them if they encounter difficulties breastfeeding, a community culture that does not support breastfeeding at all or breastfeeding in public, and continued bombardment of media and educational materials by the infant formula industry, promoting infant formula as a product with many of the same benefits as breastmilk. In fact, the influence of this advertising appears to have succeeded in convincing some women that the best choice is to give their baby both breastmilk and infant formula, so that the baby gets the supposed benefits of both. There is still much work to be done! On the policy level, where we can potentially have the greatest population impact, we need to find legislative and regulatory solutions to support women's infant feeding decisions. These include advocating for increased accommodations at the workplace, additional funding for Special Supplemental Nutrition Program for Women, Infants and Children breastfeeding peer counselors, and reining in of the infant formula industry's aggressive and misleading marketing efforts.

Local and state health departments have an important role to play in all these efforts, through continued monitoring of breastfeeding rates and trends, and sharing data with community and hospital providers; working with hospitals to standardize data collection and to use data for program evaluation and to inform action; providing training and technical assistance to hospitals to implement best practices and become Baby-Friendly; promoting inter-agency collaboration and community engagement to support breastfeeding; supporting adequate agency capacity and funding to assure sustainable efforts; and advocating for policy changes at the local, state, and federal levels to support breastfeeding and to reduce the influence of the infant formula industry on infant feeding decisions. We are well on our way to making breastfeeding the norm in NYC, and through a sustained and coordinated effort we believe that more and more women will successfully breastfeed their babies.