How We Did It

In December of 2005, Massachusetts put forth newly revised hospital regulations that significantly strengthened breastfeeding education, promotion and support in the state’s maternity hospitals. The new regulations gained considerable press because they established Massachusetts as the first state to prohibit the direct marketing of infant formula to mothers. Perhaps more importantly, they were part of a broader effort to promote high-quality family-centered care, set higher standards for the availability of lactation services, require on-going breastfeeding education for medical staff, and improve documentation and discharge planning of infant feeding practices.

Since Massachusetts is a pioneer in the development of the breastfeeding-friendly policies, many people have asked us how we did it. In short, the new regulations are the result of a successful alliance between the Massachusetts Breastfeeding Coalition, consumers, health care providers, and our state Department of Public Health (DPH). The Massachusetts Breastfeeding Coalition (MBC) spearheaded the effort by finding a key champion in the legislature and working with DPH to develop evidence-based guideline for breastfeeding promotion in the hospital setting. Massachusetts’ new regulations are a great example of the ability of a broad coalition to create changes through hospital policies, provider practices, state regulations, and legislation.

Background: In 1988, Massachusetts duplicated the state of New York’s breastfeeding language within its state hospital perinatal regulations. Hospital regulations are requirements that hospitals must follow to be licensed. The perinatal part of the hospital regulations included language that addressed breastfeeding promotion and support

In September of 2001, then-State Representative Jarrett Barrios convened the first meeting of a State House "working group" on breastfeeding, in response to a constituent’s letter. One of his aides gathered a group of experts from around the state to help brainstorm how to best advance breastfeeding. During the first meeting, the group decided that our initial focus should be given to supporting breastfeeding in the first two weeks after birth, when women stop due to a variety of barriers and difficulties. Most of the experts on the original eleven-members panel were also members of the Massachusetts Breastfeeding Coalition, a group of that had been founded in 1998 and whose major activities included the issuing a yearly Resource Guide for providers. Our state was fortunate to have several nationally known breastfeeding experts who also served on the panel: Marsha Walker, RN, IBCLC of the National Alliance for Breastfeeding Advocacy; Cindy Turner-Maffei, MA, IBCLC of Baby Friendly USA; Karin Cadwell, PhD, RN, IBCLC of Healthy Children; and Anne Merewood, MA, IBCLC of Boston Medical Center. By September 2001, at the request of Rep. Barrios’ aide, the taskforce was coordinated by internist and nursing mother, Dr. Melissa Bartick – the constituent who wrote the original letter to Representative Barrios.

The working group held all its meetings in the State House. This location was key, because influential people took the meetings very seriously, and nearly all came when invited. At our meetings, we made it clear that lack of breastfeeding was not just an issue about babies, but that it affected all segments of society in terms of risks of costly chronic disease. We cited referenced data, listed the incidence in our state of many of the chronic diseases affected by not breastfeeding, and, when available, provided the costs of treating these diseases. The data we used at these meetings is summarized at www.massbfc.org/advocacy/index.html.

When the working group formed, we had planned to meet about three or four times, form a strategic plan, and then disband. At the second meeting, we were joined by staff from the Department of Public Health, including staff from the WIC (Women, Infant and Children) Nutrition Program. The group determined that updating and strengthening the breastfeeding component of the perinatal regulations to reflect current knowledge and research would be an important step towards meeting our goals. Because the development and issuance of regulations is a lengthy process, it was decided that in the interim, the DPH group could provide breastfeeding guidelines to the state’s hospitals. These guidelines were issued, in partnership with the Massachusetts Hospital Association, in April 2003. The working group also suggested that the state provide an educational brochure for each maternity patient’s hospital admission packet, something which came to fruition within a year with a guidance of MBC members.

Our working group approximately doubled in size between February and July, as other interested providers joined the panel. The energy and ideas of the new members helped expand our reach across the state. Leaders from the health insurance arena were also invited to join our meetings, and many attended with enthusiasm. The State House group continued to meet regularly until July 2002, when it officially voted to continue its mission under the auspices of the Massachusetts Breastfeeding Coalition. The groups already shared many members, and together many physicians, lactation consultants, representatives from DPH and WIC, AAP, La Leche League, Nursing Mother’s Council, National Alliance for Breastfeeding Advocacy, Baby Friendly USA, Healthy Children Project, Federation for Children with Special Needs, various hospitals, and individual health care providers. With sponsorship from the insurance industry, MBC had our first annual health care providers’ conference in September 2002, and our growing budget allowed us to pursue other important activities to support breastfeeding and train providers.

The Regulation Writing Process: In March 2003 the DPH created a broad-based taskforce to work with the Department to revise the existing perinatal regulations. This task force included interdisciplinary representation from all over our state. Several MBC members were invited to be on the taskforce, both to address breastfeeding recommendations and as representatives of other groups concerned with child welfare. At the meetings, Marsha Walker provided research on the effects of formula marketing on breastfeeding. Other MBC members who participated on the task force included Barbara Popper of the Federation for Children of Special Needs (who also was a member of the 1988 Perinatal Task Force), Cindy Turner-Maffei, Karin Cadwell, and Dr. Melissa Bartick, who had become chair of MBC in 2002.

Within the Department of Public health, collaborations between the WIC Program and the Title V Maternal and Child Health Programs created a strong presence of breastfeeding knowledge and support. However, it was bringing a community breastfeeding coalition like MBC to the table in such force that was the key to bringing change to hospital breastfeeding practices. The perinatal regulations concern many issues other than breastfeeding, and MBC’s presence made certain that issues of breastfeeding promotion, lactation support and formula marketing were clearly and thoughtfully addressed. Our members cited data whenever we could - data about the impact the formula marketing bags have on breastfeeding, data about adverse health outcomes linked to formula use, and data about the need for lactation support. It helped that many of us gave the same message: "there is no justification for hospitals to partner with formula companies to promote a product with adverse health outcomes."

MBC argued that it is both inappropriate and ineffective to allow formula marketing materials to be given out to any mother, no matter how she plans to feed her baby. While other members of the regulation revision task force expressed concern that prohibiting the marketing of formula in hospitals could limit access to formula in hospitals, thereby creating an economic hardship for low income women choosing to bottle-feed, the MBC was able to provide evidence to support their position. By June 2005, the draft perinatal regulations read that formula marketing bags could be given to nursing moms only if they ask, but everyone else can have them. To this, MBC responded, "Well, then all moms will say they will breast- and bottle-feed just so they can get the free bags." It was then recommended the language be changed to broaden the ban to all new mothers.

The final version of the draft regulations was provided to the public prior to a period of hearings when the public was encouraged to provide oral and written testimony on the proposed regulations. Through the MBC listserv and word of mouth, 47 people submitted written testimony about the gift bags. Marsha Walker alone submitted 14 pages of testimony, full of research data. Strong oral testimony came from Dr. Susan Browne, the breastfeeding coordinator of our state chapter of AAP. Strong written testimony came from OB-GYN Dr. Alison Stuebe, neonatologist Dr. Kim Lee, pediatrician Dr. Bobbi Philipp, and Dr. Bartick. Our outreach and organizing efforts were extremely successful; testimony supporting the recommended breastfeeding-friendly provisions far exceeded the pro-formula testimony. (Click here to view the DPH summary of the formula marketing testimony.)

Following the public hearings, many of the breastfeeding components of the draft regulations were adopted and approved by Massachusetts’ Public Health Council. The new regulations mandate the provision of lactation services, prohibit direct formula marketing to mothers and require continuing breastfeeding education for medical staff. They will be put into place across the state over the next several months.

The successful promulgation of the revised perinatal regulations was a joint effort between the Department of Public Health and a powerful team of players from the community. The process was a terrific learning experience, and has taught us a lot about the value of using data, common sense, and people power to accomplish a common goal.