Taleah Walton entered the delivery room at Hahnemann University Hospital last month saying she planned to breast-feed. But when her son was born, she said, the hospital staff took him and fed him formula anyway.
"I wasn't happy," Walton said.
Reunited with her son an hour or so later, the 19-year-old West Philadelphia woman had trouble initiating breast-feeding. The hospital's lactation consultant had left for the day and, Walton said, the nurse who was sent in to help her "didn't seem like she knew much."
Federal surveys put Philadelphia's breast-feeding rate among the lowest of major American cities. The reason, experts say, is likely a combination of factors that include the city's racial makeup (blacks are less likely to breast-feed), income (lower means less), and hospital practices (Hahnemann and other hospitals say they try to support the mother's wishes, but stories such as Walton's are not unusual).
"All the hospitals in Philadelphia are so stressed now," said Nikki Lee, pointing to the raft of maternity ward closings over the last decade. In her job as the city health department's lactation consultant, Lee said, she tries to convince maternity ward staff that "breast-feeding doesn't mean more work."
A conglomeration of passionate breast-feeding supporters and advocacy groups are actively working for change in other ways.
Yeshemebet Legesse, an advocate with the Maternity Care Coalition, coaches expectant and new mothers, including Taleah Walton, in breast-feeding. (DAVID SWANSON / Inquirer Staff Photographer)
The Maternity Care Coalition, commonly known as MOMobile - its "advocates" drive bright-yellow-and-purple vans to the homes of pregnant women and new mothers for free monthly visits - has been trying to bring infant mortality rates down in Philadelphia since 1980. But with limited funds and seemingly unlimited need, the coalition prioritizes who it can help; many are left out.
Walton was lucky. Before giving birth, her advocate, Yeshemebet Legesse, coached her on what to expect and how to deal with hospital staff that the advocate said is all-too-often uninterested in facilitating breast-feeding.
Besides practical matters such as teaching breast-feeding positions, Legesse tries to encourage the practice by educating clients about its health benefits - knowledge that Walton has been sharing with friends and family.
Breast-fed infants are known to experience lower rates of infectious diseases, sudden infant death syndrome, digestive illnesses, diabetes, obesity, and other maladies. Lactating mothers also slim down faster and face lower risks for some cancers.
In the early 1970s, few American women nursed their babies. Formula was seen as the technological solution to the inconvenience of breast-feeding. Since then, as science repeatedly proved breast milk's superiority, the rates have steadily increased - with significant regional variations (high in the West, low in the South, average in New England and the Mid-Atlantic).
Surveys by the U.S. Centers for Disease Control and Prevention have consistently found other disparities as well. Younger, poorer, less-educated and unmarried mothers breast-feed less. So do African Americans generally, which experts say may account for much of Philadelphia's low rate - 53 percent vs. 77 percent in Boston and 87 percent in Phoenix.
"They know that breast-feeding is the best," said Peggy Bentley, a nutrition professor at the University of North Carolina in Chapel Hill.
But knowing may not be enough. In a 2003 article in the Journal of Nutrition, Bentley explored factors associated with breast-feeding among low-income African American women in Baltimore, a city with rates similar to Philadelphia's.
She found that women's decisions to nurse are influenced by a complex mix of factors: government and hospital policies, aggressive marketing by formula producers, and standards and support in their local community, workplace and personal situation.
"They don't have boyfriends or fathers of the baby who are supportive," Bentley said. "They don't have mothers and sisters showing them how and saying they may have some difficulties."
The American Academy of Pediatrics recommends that mothers breast-feed exclusively - with no other food, formula, or even water - for six months.
"We are asking a lot of women whose lives are very complex to exclusively breast-feed," Bentley said. "Philadelphia would be like that. People just trying to survive."
Exclusive breast-feeding appears to be difficult for everyone. The national average at six months is about 11 percent.
"Basically, they are trying it and stopping," Bentley said. Plenty of programs aim to start women nursing immediately after the birth of their babies, she said, but "the duration issue, we know a lot less about that."
An experiment in how to foster exclusive breast-feeding was proceeding one sunny day last month as a fidgety, 8-week-old Thomas Wills was examined for his acid reflux at a satellite clinic of Children's Hospital of Philadelphia.
"Go ahead and feed him," said nurse Margaret D'Andrea.
His radiant mother, Toyya Wills, smiled and complied. As Thomas nursed, the grown-ups continued a discussion about the logistics - stool appearance, frequency and so on - of breast-feeding.
Children's Hospital's experimental program incorporates support for breast-feeding into routine pediatric care, partly to see if it will help women nurse longer.
All the staff at this clinic has been trained in the art of breast-feeding by Diane Spatz, principal investigator of the study and a lactation specialist with joint appointments at the University of Pennsylvania and Children's.
"We created a visually pleasing breast-feeding culture," said Spatz. "We have colorful posters everywhere with women of color breast-feeding."
A nurse checks in with new breast-feeding mothers every two weeks.
Although the study is ongoing, Spatz said it was clear that the clinic's efforts "have increased the time and exclusivity of breast-feeding."
The nurses also offer guidance on how to overcome hurdles that a nursing mother may face when she returns to work at, say, McDonald's or Wal-Mart. Is there a clean, private room to express breast milk? Time to pump? A refrigerator to keep the milk cool during the work day?
"I'm scared," admitted Wills, who works at Greyhound. If her boss is not OK with it, she said, she'll pump in the bathroom. "I'd bring a sanitizer."
Both Wills and Walton, the mother from Hahnemann, participate in the Women, Infants and Children federal nutrition program for low-income pregnant mothers and their young children. WIC rents breast pumps to mothers who work or go to school; it also provides free formula to women who choose not to breast-feed.
When Wills went to a WIC office near her University City home, she said, she turned down an offer of formula because she was planning to nurse her baby. The WIC employee's response was "are you sure?" she said. Added Walton, separately, "They didn't encourage or discourage me" to breast-feed.
A WIC official said questioning a mother's decision to breast-feed would violate policy.
Meanwhile, Walton seems to have gotten past the initial barriers she faced in the hospital. Her son, Tariq Owens Jr., is still being breast-fed, though not exclusively, at 5 weeks of age. Walton originally had hoped to nurse her baby for two months, but now thinks she can go longer.
She lives with her mother and sister, Dominique Summer, 16, who had her first child just last week. Walton is especially pleased with her own decision to nurse, she said, "because now my little sister is going to breast-feed." She's trying to, anyway. | 
