"This has really been a sea change in our birthing hospitals," said Bette Begleiter, deputy executive director of the Maternity Care Coalition, which jump-started the campaign with a summit in 2011.
Only Pennsylvania Hospital, with 4,400 births a year, the most in the city, had already moved to "ban the bags," as the national movement is known. The others followed, one by one: Thomas Jefferson University Hospital, the Hospital of the University of Pennsylvania, Einstein Medical Center, Temple University Hospital, and the last, Hahnemann University Hospital, in April.
Hahnemann distributed about 2,100 diaper bags, one for each baby, in 2013, a spokeswoman said. The bags, each containing two cans of formula along with educational materials and discount coupons, were provided by the manufacturers.
That relationship is the crux of the issue, according to leaders of the movement.
"What companies have done is co-opted health-care providers into doing their marketing for them," said Marsha Walker, Boston-based executive director of the National Alliance for Breast-feeding Advocacy. Hospitals become the source of the formula; mothers "think it is good for them," Walker said.
Pediatricians get patients who have already started on free formula. "When mothers go home and they are struggling a little bit with breast-feeding, they reach for that bottle," said Deborah Sandrock, a pediatrician at St. Christopher's Hospital for Children. Young mothers in the city may have a tougher time because they often don't know other women who breast-fed and could help them figure out what to do, she said.
Extensive research shows that breast-feeding improves the health of babies on a range of measures (ear infections down as much as 50 percent compared with formula feeding, in several studies; infants' risk of hospitalization from lower respiratory tract diseases down 72 percent; asthma down 27 percent; type 2 diabetes down 39 percent in later life). Mothers who breast-feed have significantly lower rates of breast and ovarian cancer. Hospitals, insurers, companies, and governments save considerable amounts on health-care costs.
"It is still the choice of the mom if she breast-feeds or not," but now she is making the decision free of marketing influence, said Katja Pigur, who led the ban-the-bag campaign for the Maternity Care Coalition, known among the public for its MOMobile.
Two states - Rhode Island and Massachusetts - and Portland, Ore., have gone bag-free; New York's city-owned hospitals have done so as well. Philadelphia's campaign was unusual, however, because it came from the hospitals.
Changing institutional practice required "a real mind-set change," said Terry O'Brien, a registered nurse who cochaired the initiative at Jefferson, which dropped the bags in January 2012.
Longtime formula company representatives were "fairly entrenched" among maternity nurses, she said. The hospital now buys formula for women who request it. Instead of the nondescript vinyl bags provided by the formula makers, the hospital designed - and paid for - new ones with its own marketing message: "Jefferson Delivers Every Step of the Way."
The push to neutralize corporate influence coincides with efforts nationally to reduce conflicts of interest in health care. And while the formula reps "never said that breast-feeding wasn't good," said Martha Puleo, another Jefferson nurse, others in the field said that the companies responded by increasing formula giveaways to OB/GYNS, pediatricians, and even centers where pregnant women go for ultrasounds.
A spokeswoman for Abbott Laboratories, which sells Similac to Jefferson, did not return a phone call requesting comment. Enfamil manufacturer Mead Johnson referred a reporter to the International Formula Council.
"Focusing on infant feeding support kits detracts from the real barriers to breast-feeding such as access to health care after leaving the hospital, breast-feeding support in the workplace, and paid or longer maternity leave," Mardi Mountford, executive vice president of the Atlanta-based council, said in a position statement. "Further, suggesting moms can be swayed from breast-feeding by receiving information on infant formula or a small sample does a great disservice to them," the statement said.
For hospitals here and around the country, banning formula giveaways is just one of 10 steps toward a coveted "Baby Friendly" designation, an extensive and time-consuming process originally set up by the World Health Organization.
All Philadelphia hospitals have achieved another step in the process, known as "skin to skin" - implementing policies that ensure newborns are placed on their mother's chest for a "golden hour" after birth, before being weighed and washed, to help them bond and latch onto the breast.
"It was actually really nice," said Rachel McGinn, who distinctly remembers when the youngest of her three children was placed on her chest.
A surgical trauma nurse who lives in Langhorne, she delivered all three of her children at Jefferson and exclusively breast-fed all of them; she is still trying to get 19-month-old Lilah to give it up.
When Makayla was born, in 2008, McGinn was given free formula and threw it out. She probably was offered it when her son, Carter, was born three years later, but said she didn't want it. By the time Lilah arrived in December 2012, the hospital had stopped giving it out.
She never noticed.
"We anticipated a bigger problem than we actually had. Patients asked, [we] said no, and they said, 'Oh, great,' " said O'Brien, the nurse educator who is working on Jefferson's multi-phased application for Baby Friendly designation.
Currently, 193 hospitals and birthing centers in the United States, accounting for fewer than 8 percent of births, have received the designation. Four New Jersey hospitals are Baby Friendly, including Inspira Medical Center in Elmer, Salem County.
Reading Birth and Women's Center in Berks County was the third in the United States to earn the designation, in 1997, but only one other in Pennsylvania has done so since: Lancaster General Women and Babies Hospital, last month.
In a breast-feeding report card released Thursday, the U.S. Centers for Disease Control and Prevention ranked Pennsylvania in the bottom 10 on two out of five measures of breast-feeding support.
The Philadelphia task force hopes to change that reputation, at least for the city. Its "bag-free Philadelphia" announcement, timed for Friday's start of World Breast-feeding Week, also will declare Philadelphia "The City of Motherly Love."
Rates of Women Who Ever Breast-Fed
United States . . . 79.2%
Delaware . . . 65.7%
New Jersey . . . 81.6%
Pennsylvania . . . 72.9%
Philadelphia* . . . 62.2%
* "Breast-feeding initiation" rather than "ever breast-fed" (Pa.'s initiation rate was 71 percent).
SOURCES: U.S. Centers for Disease Control and Prevention; Pennsylvania Health Department