In 1989, an international panel of experts called attention to the irony that health workers were preventing many newborns from getting the healthiest possible food - mother's milk.
Hospital maternity units were contributing, "however unwittingly," to the long decline in breast-feeding by failing to encourage moms to do it, or by introducing practices that discourage it, such as giving baby formula.
The panel's statement, sponsored by the World Health Organization and United Nations Children's Fund, led to a global hospital reform movement called Baby Friendly.
Now, a few decades later, the movement has taken root in Philadelphia, where breast-feeding rates are perennially lower than the state's, which are lower than the nation's. All six of the city's birthing hospitals have committed to investing four years - and considerable capital - to adopt 10 practical steps that promote breast-feeding, including keeping newborns with mothers rather than in a nursery, and not sending them home with free formula.
The region's Maternity Care Coalition, a nonprofit dedicated to improving maternal and child health, planted the seeds of Baby Friendly in 2011.
"You think, 'Ten steps, that's easy. Why do they give us four years to do this?' " said Anneliese Gualtieri, a nurse in the mother-baby unit at Einstein Medical Center, with 3,000 deliveries a year. "But changing practice and the culture is very difficult."
The Hospital of the University of Pennsylvania and its affiliate, Pennsylvania Hospital - with more than 8,000 deliveries a year - are closest to earning the coveted Baby Friendly designation from Baby Friendly USA, the nonprofit accrediting firm in Albany, N.Y. Both hospitals jumped through the final hoop of site visits about two months ago.
Rachel Montgomery, 36, of Media, can attest to the changes in atmosphere and attitudes at Pennsylvania Hospital, where she gave birth three years ago - and 13 days ago.
"I've been a pediatric nurse, so I know a lot about [Baby Friendly] and was elated to see it," she said. "I knew I was going to have a better experience with my second son, and I did."
The nutritional, health, and psychological benefits of breast-feeding are undisputed. It's also more economical than formula. Yet barely 80 percent of U.S. mothers ever do it - meaning 20 percent don't, according to the most recent survey by the Centers for Disease Control and Prevention. (The survey found about 73 percent of Pennsylvania mothers and 82 percent of New Jersey mothers ever breast-fed.)
Baby Friendly helps medical professionals confront how they may be contributing to this situation by getting in Mother Nature's way.
Consider what normally happens to a healthy baby delivered in a modern hospital: The infant is whisked away, weighed and measured, treated with a vitamin K shot to prevent bleeding, given antibiotic eyedrops, bathed, wrapped in a blanket, and put under a warming lamp in the nursery while Mom recovers.
"Mom was given back a sweet, clean baby," said Trish MacEnroe, executive director of Baby Friendly USA. "What we failed to realize was the normal biological instincts we were interfering with."
In contrast, in the nation's 267 (and counting) Baby Friendly hospitals, healthy newborns are wiped off and spend their first hour on their mother's chest so they can begin breast-feeding and bonding. Studies show this helps infant vital signs, including heart rate and body temperature.
Even women who deliver by cesarean section, like Montgomery, can welcome their newborns "skin-to-skin." After the nurse helped Montgomery with Rowan's first feeding, his initially low blood sugar normalized.
"I would say it's a testament to this practice and how effective it is," Montgomery said.
And if cuddling before cleansing sounds unsanitary, studies show it lowers the chance of infection.
"The thing is, you want the baby to be colonized with the mom's bacteria, not bacteria from the nursery," said obstetrician-gynecologist Gail Herrine, director of Temple University Hospital's postpartum unit. "We're not bathing the baby for 12 to 24 hours, and Mom can participate in the bath."
Some women, of course, say they prefer not to breast-feed. Baby Friendly nurses are trained to find out why. A lack of role models? Concern about discomfort, inconvenience, or embarrassment? Not sure how to maintain lactation after going back to work?
Then they explain why the breast is best.
This is particularly important with low-income women, who generally have lower breast-feeding rates.
"It's not that you're forcing the mom to breast-feed," said Gualtieri at Einstein. "You're educating her so she can make an informed choice."
"I think there were perceptions that certain mothers won't breast-feed, or don't breast-feed," MacEnroe of Baby Friendly said. "But when the benefits are pointed out to them, they are eager to do it. Every mother wants to do what's best for her baby."
To enable breast-feeding on demand, infants remain in their mothers' rooms around the clock during the two- to four-day hospital stay. Health workers are on hand to teach about colostrum, breast pumps, and relieving sore nipples - while resisting the urge to try to help an exhausted new mother by removing the baby and giving a bottle of formula.
"Rooming in was a difficult transition for the staff," said Kathleen Sibre, nurse manager of the maternal-infant unit at Jefferson Hospital. "Now it's routine. Ninety percent of the time, my nursery is dark."
Cooper University Hospital in Camden grappled with the difficulty of getting staff on board six years ago, when it was in the vanguard of adopting another Baby Friendly tenet: Don't send mothers home with a bag of free formula from manufacturers, a decades-old practice that effectively turns hospitals into formula marketers.
To see whether the change made a difference, Cooper did a study comparing women who did and did not get the bags of formula. Exclusive breast-feeding was more common at 10 weeks among the latter group, but just barely. It turned out that clinicians, worried that poor urban babies would go hungry, slipped formula to the mothers in violation of the study protocol.
"It was good intentions," said Cooper pediatrician Lori Feldman-Winter, who led the study. "But it was also the idea that breast-feeding isn't enough, thatno matter what we do, mothers in this community won't breast-feed. As opposed to saying: Maybe what we as clinicians are doing is changing breast-feeding patterns."
Since then, Cooper has successfully "banned the bag," and more than half of its new mothers are breast-feeding when they go home.
Last year, Philadelphia's birthing hospitals also banned the bag, joining a national transformation. A CDC study published last month reported that only 32 percent of hospitals gave out the freebies in 2013, down from 73 percent in 2007.
The financial investment in baby friendliness is not trivial. Besides training costs, hospitals pay $11,000 to Baby Friendly USA for help setting up, plus $1,200 a year. Hospitals also swear off free formula, even for use in maternity units.But the initiative already seems to be yielding results in Philadelphia. In the summer of 2012, the city's six birthing hospitals had an average breast-feeding initiation rate of 49 percent; last summer, the rate had climbed to 59 percent.
"The data we have now is the first from our work, but it's already impressive," said Katja Pigur, the Maternity Care Coalition's director of breast-feeding services. "I expect the rates will really go up in the next two years."