SummaryA citywide initiative of the New York City Department of Health and Mental Hygiene, Latch On NYC asks the city’s public and private maternity hospitals to commit voluntarily to concrete steps to support mothers who choose to breastfeed and eliminate practices that interfere with that choice. Participating hospitals make four commitments: putting in place policies and processes to ensure compliance with State regulations (which include not providing supplemental formula feedings during the inpatient stay and/or formula packages at discharge unless the doctor orders or the mother requests them), implementing systems for tracking and storing formula, discontinuing distribution of free infant formula, and prohibiting the display and distribution of promotional materials for formula in the hospital. The Department of Health and Mental Hygiene supports hospitals in meeting these commitments by offering technical assistance, providing periodic performance reports, convening meetings to share information and best practices, distributing educational materials, and conducting a complementary breastfeeding promotion campaign. Latch On NYC has achieved notable uptake by the city's maternity hospitals (with 73 percent participating) and has won broad support within the medical community. Preliminary data suggest that it has had a positive impact on the number of women choosing to breastfeed exclusively during their hospital stay, an important determinant for exclusive breastfeeding after discharge.Moderate: The evidence consists of preliminary data comparing rates of exclusive breastfeeding during the hospital stay by mothers at participating hospitals during a 3-month period after program implementation with the same period a year earlier (before implementation of Latch On NYC). Additional evidence includes post-implementation data on the number of maternity hospitals in the city signing on to the program and support of the program by key stakeholders within the local medical community.
Developing OrganizationsNew York City Department of Health and Mental Hygiene
Date First Implemented2012
The Commissioner of Health officially announced the launch of Latch On NYC at a press conference on May 9, 2012. Hospitals had until September 3, 2012, to fully implement the initiative.
Gender > Female; Age > Newborn (0-1 month); Vulnerable Populations > Women
Problem AddressedDespite substantial evidence documenting the benefits of breastfeeding and the health risks associated with formula feeding, many hospitals routinely provide supplemental formula feedings to newborns and allow formula samples and promotional materials in the hospital and in gift bags given to mothers. These actions have a negative impact on breastfeeding duration and exclusivity (i.e., breastfeeding without supplementing with formula).1,2
- Many benefits to breastfeeding: Breastfeeding is good for both mother and baby. Mothers who breastfeed have a lower risk of breast and ovarian cancers, and infants who are breastfed have a lower risk of diarrhea; vomiting; and ear, respiratory, and gastrointestinal infections.3 Because of these benefits, the American Academy of Pediatrics, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) recommend exclusive breastfeeding until an infant is 6 months old.4
- Hospital practices related to formula use and promotion: Many hospitals routinely provide supplemental formula feedings to newborns whose mothers have expressed a desire to breastfeed. Before implementation of this initiative, 93 percent of births in New York City occurred in hospitals that routinely supplemented healthy breastfed infants with formula.5 In a nationwide evaluation, New York State was second only to New Jersey in having the highest percentage of breastfed newborns given supplemental formula feedings in the hospital.6 In addition, many hospitals routinely allow promotional materials for infant formula in the hospital and often give mothers gift bags that include formula samples and marketing materials.
- Impact of hospital practices on breastfeeding exclusivity and duration: The vast majority (89 percent) of mothers in New York City start breastfeeding, yet only 26 percent of them still breastfeed exclusively after 2 months.7 Providing formula to a breastfed baby, particularly in the first few days after birth, contributes to this decline in breastfeeding rates, as it can undermine the infant’s ability to breastfeed and reduce the mother’s milk supply, which in turn makes the mother more likely to decide to stop breastfeeding.4 In addition, breastfeeding mothers report that receiving free formula at hospital discharge makes them feel that breast milk alone is not enough for their babies.4 In New York City, the most common reasons that women stop breastfeeding are concerns about breast milk supply (with 47 percent of women who give up breastfeeding citing this reason) and concerns that the infant is not satisfied with breast milk alone (42 percent).7 In most cases, these beliefs are unfounded and can be addressed with education and support.8
Description of the Innovative ActivityA citywide initiative, Latch On NYC asks the city’s public and private maternity hospitals to commit voluntarily to concrete steps to support mothers who choose to breastfeed and to eliminate practices that interfere with this choice. The Department of Health and Mental Hygiene (hereafter referred to as "the Department") supports hospitals in meeting these commitments by offering technical assistance, providing periodic performance reports, convening meetings to share information and best practices, distributing educational materials, and conducting a complementary breastfeeding promotion campaign. Key program elements are outlined below:
- Four commitments to support breastfeeding mothers: Participating hospitals sign an agreement that includes four distinct commitments related to supporting mothers who choose to breastfeed exclusively. The signed documents must include a letter from the hospital’s chief executive officer (CEO) indicating his or her support for the hospital’s participation. The commitments are outlined below:
- New or revised policies and processes to ensure compliance with State regulations: Participating hospitals agree to develop new policies and processes (and/or revise existing ones) to ensure compliance with New York State regulations regarding supplementation of breastfed infants. These regulations state that hospitals can use supplemental feedings only when medically indicated (due to a medical condition of the newborn or mother) or when requested by the mother.9 Hospitals agree to provide documentation of these policies to the Department; hold an inservice training for hospital staff on the new and/or revised policies; and review or develop systems to ensure that the need for supplementation is clearly documented in the medical record.
- Systems and process to store and track formula: Participating hospitals commit to implementing systems and processes to store infant formula and to track and share data on its distribution with the Department. These data are used to monitor the impact of the program over time. To assist with this process, the Department suggests that participating hospitals have staff perform periodic walkthroughs to determine the current flow of infant formula (e.g., where it is stored, who handles it, how it is tracked) and put in place appropriate policies for storage and handling that improve staff accountability and compliance with Latch On NYC commitments.
- No formula giveaways: Participating hospitals agree not to provide promotional and free formula to mothers, including placing formula samples and related supplies (e.g., feeding bottles, nipples/teats) in gift bags given at discharge, unless the attending practitioner orders them or the mother requests them. Any mother who expresses a desire to feed with formula after discharge but cannot afford it is referred to the Women, Infants, and Children program (WIC), a Federal food and nutrition program that serves low-income families, or to the social services department of the hospital.
- No promotional materials: Participating hospitals agree not to display anywhere in the hospital or distribute to mothers any promotional materials for formula (e.g., posters, pens, crib cards, lanyards, diaper bags). They also agree not to allow representatives of formula companies on maternity units. Participating hospitals are encouraged to conduct a monthly walk-through to ensure that no promotional items for formula are on hospital premises.
- Additional pledge to educate and train hospital staff: While not a formal commitment, the Department encourages participating hospitals to train and instruct their staff to educate mothers on how to breastfeed successfully; to assess, educate, and counsel any mother who reports problems or concerns related to breastfeeding; and to refer these mothers to other services (e.g., certified lactation counselors, home visiting program) if additional help with breastfeeding is required.
- Mechanisms to support hospitals in meeting commitments: The Department supports participating hospitals in meeting the Latch On NYC commitments in various ways, as outlined below:
- Needs assessment and periodic surveys: The Department distributed a comprehensive needs assessment to hospitals that initially signed on to Latch On NYC. This assessment helped program leaders understand to what extent hospitals were meeting program commitments and identify common challenges and concerns. This information has been used to determine the best ways to support hospitals, including topics to be covered during bimonthly webinars (described in more detail below). The Department periodically asks participating hospitals to fill out additional, shorter surveys to help program staff tailor ongoing support to their real-time needs.
- Work plan template and associated support: The Department provides participating hospitals with a template that covers the key steps and processes needed to meet each commitment. Most hospitals establish a multidisciplinary team (or use an existing one) to work through the template to create an implementation work plan. Department staff are available to guide the team through this process.
- Periodic performance reports: Participating hospitals receive periodic performance reports that show trends in breastfeeding rates, including the proportion of mothers who breastfeed exclusively. (These data come from information recorded on the baby’s birth certificate.) The report also shows trends in the number of formula bottles distributed per eligible infant (defined as any infant born in the institution, except those in the neonatal intensive care unit, being adopted, held by child protective services, transferred in or out of the birth institution, whose mothers have died, and/or who have at least one contraindication to breastfeeding). For every indicator, each hospital receives information on its performance, along with comparisons with the minimum, maximum, and average performance among Latch On NYC hospitals. Department staff conduct conference calls and site visits with hospitals that have the highest number of bottles distributed to eligible births, with the goal of helping them identify and implement new strategies to reduce supplementation.
- Technical assistance: The Department provides technical assistance to help participating hospitals adhere to the commitments and meet the initiative’s reporting requirements. Staff are available by telephone, e-mail, or for onsite visits, as requested, to help with specific issues and challenges. A physician from the Department can also conduct grand rounds on breastfeeding and meet with key stakeholders, including physicians and nurses from pediatrics and obstetrics. During these meetings, staff typically review the hospital’s performance report and address any issues or challenges the hospital is facing. Recently, the CEO of a participating hospital attended one of these grand rounds to reiterate the importance of complying with Latch On NYC requirements and supporting mothers who want to breastfeed.
- Sharing information and best practices: The Department hosts webinars for participating hospitals every 3 to 4 months. These meetings provide an opportunity for participants to receive guidance from Department staff and to share updates, challenges, successes, and lessons learned with each other. The Department also hosts a listserv that can be used by participating hospitals to post questions, discuss issues, and share practices. Collectively, these approaches serve to create and foster a learning community among participating hospitals.
- Training for hospital staff (also available to nonparticipating hospitals): The Department sponsors periodic training sessions for hospital-based staff to become certified lactation counselors (a 45-hour course) or trainers in breastfeeding education (a 20-hour course). Any hospital in the city (including those that have not signed on to Latch On NYC) can participate in these sessions.
- Breastfeeding promotion campaign: Latch On NYC conducted a campaign to promote the benefits of breastfeeding, including reducing the infant’s risk of ear infections, diarrhea, and pneumonia. The campaign also informed women of their right to receive education and support for breastfeeding their babies if they choose to do so. The campaign consisted of advertisements placed online and in the city subway system (which ran for 6 weeks during the program's launch) and posters provided to participating hospitals for display in prenatal clinics, WIC centers, and maternity wards. (These posters remain on display.) Additionally, the Department developed noncommercial promotional materials (e.g., lanyards, pens, tote bags) with the Latch On NYC logo for key hospital staff.
Context of the InnovationOne of the world’s largest and oldest public health agencies, the Department oversees a multitude of public health initiatives in the city. The agency has an annual budget of $1.6 billion and more than 6,000 employees; its accomplishments include a comprehensive tobacco control program, the elimination of trans fats in restaurant food, a requirement for chain restaurants to post calorie information on menu boards, and development of an electronic health record for use by health care providers citywide.
The roots of Latch On NYC go back to 2005, when the Department surveyed Health and Hospital Corporation (HHC) hospitals (i.e., New York City's public hospitals) to find out what, if anything, they did to support mothers who wanted to breastfeed. Survey findings suggested that hospitals did not provide much support in this area and needed help in doing more. As a result, the Department partnered with HHC leaders on a comprehensive program to help public hospitals in the city become more breastfeeding friendly by implementing some of the steps required to become certified by Baby-Friendly USA, the U.S. branch of the Baby-Friendly Hospital Initiative, which was launched by WHO and UNICEF in 1991 as a global effort to implement practices that protect, promote, and support breastfeeding. This initiative contained some of the key elements of what later became Latch On NYC, including working with hospitals to implement best practices in breastfeeding promotion and support. Around the same time, New York State regulators began increased monitoring of hospital standards and policies on breastfeeding.
In 2008, with additional support from CDC, the Department expanded its efforts to more hospitals and began pursuing strategies to reduce the negative impact of marketing by the infant formula industry on a mother's decision to breastfeed. Department staff published a research paper documenting the negative impact of infant formula industry practices on breastfeeding rates. The Department also offered educational materials, training, and workshops to providers and consumers; partnered with community- and faith-based organizations; and implemented an employee lactation program as part of a multifaceted initiative to promote breastfeeding.
ResultsLatch On NYC has achieved notable uptake by the city's maternity hospitals (with 73 percent participating) and has won broad support within the medical community. Preliminary data suggest it has had a positive impact on the number of women choosing to breastfeed exclusively during their hospital stay.
Moderate: The evidence consists of preliminary data comparing rates of exclusive breastfeeding during the hospital stay by mothers at participating hospitals during a 3-month period after program implementation with the same period a year earlier (before implementation of Latch On NYC). Additional evidence includes post-implementation data on the number of maternity hospitals in the city signing on to the program and support of the program by key stakeholders within the local medical community.
- Notable uptake: To date, nearly three-quarters of the city’s maternity hospitals (29 of 40 hospitals) have signed on to Latch On NYC.
- Broad support in medical community: Major organizations within the local medical community have endorsed Latch On NYC, including the New York State Department of Health, the Greater New York Hospital Association, HHC, and the New York State chapters of the American Academy of Pediatrics, the Academy of Family Physicians, and the Society for Adolescent Health and Medicine.
- Preliminary evidence of positive impact on exclusive breastfeeding in hospital: While it is too soon to gauge Latch On NYC's long-term impact on breastfeeding rates, the Department observed a significant 5.3-percent increase at participating hospitals in the proportion of women breastfeeding exclusively while in the hospital during the 3-month period between June and August of 2013, compared with the same period a year earlier (before Latch on NYC had been implemented). During the same period, there was no change in exclusive breastfeeding during the hospital stay in facilities that did not participate in Latch On NYC.10
Planning and Development ProcessKey steps included the following:
- Conducting formative research: In 2010, the Department received grant funding from CDC’s Communities Putting Prevention to Work initiative. The Department used this funding to conduct background research to inform the development of Latch On NYC.
- Focusing attention on issue in tandem with Surgeon General's Call to Action: In 2011, the U.S. Surgeon General issued a Call to Action to Support Breastfeeding, which included a recommendation that the marketing of infant formula be conducted in a way that minimizes any negative impact on exclusive breastfeeding. This report helped to focus attention on the issue.
- Developing program components: Based on its formative research and experience working with HHC hospitals, the Department developed Latch On NYC's components, including the four commitments required of participating hospitals, the supportive services to be offered by the Department, and its evaluation plan.
- Creating breastfeeding promotion campaign: A team of communications experts developed the breastfeeding promotion campaign.
- Launching initiative with high visibility: The Commissioner announced Latch On NYC at Harlem Hospital, the first hospital to be certified as a Baby-Friendly Hospital in New York City. The press event, in which leaders of HHC and executives from more than half of the maternity hospitals in the city participated, received extensive media coverage.
Resources Used and Skills Needed
- Staffing: The program did not require the hiring of additional staff. Rather, existing Department staff participated in its planning and oversee its implementation. Staff involved in this initiative have experience and skills related to program development and administration (including expertise in issues related to breastfeeding), research and evaluation, and communications, as well as experience working in a hospital setting. Through several years working with hospitals in New York City, staff have developed a high level of credibility and strong trusting relationships with leaders and staff at many hospitals.
- Costs: Data on program costs are unavailable, as there is no separate budget for Latch On NYC.
Funding SourcesCenters for Disease Control and Prevention; New York City Department of Health and Mental Hygiene
As noted previously, a grant from CDC’s Communities Putting Prevention to Work covered some of the planning and development costs. The Department funds the ongoing costs of Latch On NYC through its operating budget.
Tools and Other ResourcesMore information about the Latch On NYC program, including links to the subway advertisements and hospital posters, can be found at: http://www.nyc.gov/html/doh/pregnancy/html/after/breast-feeding-latchon.shtml.
More information about the Baby-friendly Hospital Initiative can be found at: http://www.who.int/nutrition/topics/bfhi/en/index.html.
More information about Baby-Friendly USA can be found at: http://www.babyfriendlyusa.org/.
More information on New York State regulations relevant to this program can be found at: http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/11fb5c7998a73bcc852565a1004e9f87/
Getting Started with This Innovation
- Build on existing partnerships: Latch On NYC was an outgrowth of an earlier partnership between the Department and public hospitals in the city, and its success in gaining buy-in and recruiting participating hospitals stems, in large part, from the high levels of trust and the good working relationships that had developed over the years.
- Do not create “bad guys”: The underlying philosophy behind Latch On NYC is to support hospitals willing to commit to helping mothers who want to breastfeed. As a result, the program and accompanying media campaign did not criticize hospitals or mothers for feeding infants formula but rather focused on creating an environment that supports mothers who choose to breastfeed.
- Seek buy-in and support from the medical community: The initial recruiting effort and the long-term sustainability of the program depend largely on securing the support of the medical community, including physicians and hospital associations.
- Ensure that senior hospital leaders support program: It is challenging for hospitals to make these changes in the absence of strong leadership support. Consequently, as noted earlier, Latch On NYC requires the CEO to write a letter pledging support of the initiative as part of the signup process.
- Require data reporting, but keep requirements simple: Mandatory reporting for participating hospitals creates accountability, allows for monitoring and evaluation, and provides an incentive to hospitals when they see their performance compared with that of other hospitals. While such reporting is critical, keeping requirements simple makes hospital participation feasible. Consequently, program leaders interested in such an initiative need to develop clear hypotheses about what they expect to find and then ask hospitals only for the data needed to test these hypotheses.
Sustaining This Innovation
- Create learning community among participants: To foster a learning community, provide participating hospitals with opportunities to share questions, challenges, successes, best practices, and lessons learned on a regular and ad hoc basis. Hosting regularly scheduled webinars and/or a project listserv can help to engender such a community.
- Encourage hospitals to create program-specific committees: Participating hospitals will be more likely to remain engaged in the program if they establish multidisciplinary teams that can be champions for the initiative. With Latch On NYC, these teams work closely with the Department on program components.
- Ensure that some program staff have hospital experience: Participating hospitals will remain more engaged in the program if they can work with governmental staff who have experience in the hospital setting and understand the challenges they face. If individuals with this kind of background are not available in-house, consider hiring an outside consultant with such experience to work with participating hospitals on an ongoing basis.
- Provide initial and ongoing support with data collection: Even if requirements are simple, participating hospitals may struggle with program-related data collection and analysis. To address this challenge, Department research staff are available to help participating hospitals set up and administer the requisite data tracking systems.
- Use “data-to-action” approach: Require the submission of monthly data and share hospital-specific data that show how each hospital compares with the average for all participating hospitals. Share these data with hospital leadership and staff.
- Offer educational courses: The breastfeeding educational programs offered by the Department serve as a valuable complement to the program.
- Seek funding for participating hospitals: Hospitals often do not have the financial resources to implement programs to support mothers who want to breastfeed. Any outside funding that can be made available helps keep these resource-constrained hospitals engaged and active in the program.
Contact the InnovatorAmber Ahmad-Baker, MPH, CLC
Program Initiatives Director, Maternal and Child Health Unit
Bureau of Maternal, Infant and Reproductive Health
NYC Department of Health and Mental Hygiene
42-09 28th Street, 10th Floor, 10-126
Queens, NY 11101
Marta Kowalska, MPH, CLC
Breastfeeding Initiatives Manager
Bureau of Maternal, Infant and Reproductive Health
NYC Department of Health and Mental Hygiene
42-09 28th Street, 10th Floor, 10-126
Queens, NY 11101
Innovator DisclosuresMs. Ahmad-Baker and Ms. Kowalska reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.
References/Related ArticlesNew York City Department of Health and Mental Hygiene. Latch On NYC: a hospital-based initiative to support a mother’s decision to breastfeed. Available at: http://www.nyc.gov/html/doh/downloads/pdf/ms/initiative-description.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
CBS News. Mayor Bloomberg’s infant formula plan aimed at promoting breast-feeding in NYC hospitals. July 30, 2012. Available at: http://www.cbsnews.com/8301-504763_162-57482086-10391704
Kaplan DL, Graff KM. Marketing breastfeeding—reversing corporate influence on infant feeding practices. J Urban Health. 2008;85(4):486-504. [PubMed]
Rosenberg KD, Eastham CA, Kasehagen LJ, et al. Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public Health. 2008;98(2):290-5. [PubMed]
Donnelly A, Snowden HM, Renfrew MJ, et al. Commercial hospital discharge packs for breastfeeding women. Cochrane Database of Systematic Reviews. 2000(2):CD002075. [PubMed]
5 New York City Department of Health and Mental Hygiene, Bureau of Vital Statistics. Summary of Vital Statistics 2010, The City of New York: Pregnancy Outcomes.
6 Centers for Disease Control and Prevention National Immunization Survey, Provisional Data, 2008 Births. Ranking of 50 States and Washington, DC.
7 New York City Pregnancy Risk Assessment Monitoring System (NYC PRAMS), 2011. Limited to women whose infants were living with them at time of PRAMS survey.
10 New York City Department of Health and Mental Hygiene. Bureau of Vital Statistics, 2012-2013, Preliminary data.
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Original publication: August 13, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.