There also needs to be more support once mothers leave the hospital, the state recommendations say. It is often at home, where mothers don't have a nurse helping them along, that they may be tempted to give a baby formula when breast-feeding becomes difficult.

To cut down on this temptation, the state recommendations are asking that hospitals voluntarily stop giving out coupons and free samples of formula in goody bags mothers get when they leave the hospital.

A representative with the formula industry disagreed with the assumption and said formula is not what causes mothers to stop breast-feeding.

Candice Gulden, a spokeswoman for the International Formula Council, said societal pressures and lack of work support are what stop mothers from breast-feeding. She points out that breast-feeding rates are going up even as the samples are given out.

"We think giving out a sample is educational and no one is saying you have to give this to your baby," Gulden said.

Gulden said there also needs to be support for mothers who try breast-feeding and determine it's not right for them, or for those who can't breast-feed for medical reasons. Those women should not be left out in the breast-feeding debate, she said.

"Breast-feeding and formula are both good options," Gulden said. "Breast-feeding is certainly preferred, but a good nutritional alternative is infant formula."

Some Maryland hospitals are already looking to ban the free samples.

"We are actively evaluating the free samples," said Henry J. Sobel, department chair of women's and children's services at Anne Arundel Medical Center. "We haven't made the final decision yet, but there is a lot of support for doing it."

Sobel said the hospital mostly agrees with the state's recommendations and already has several programs in place, including prenatal feeding classes run by lactation consultants and a "warm line" — a nurturing sort of hot line — that mothers can call if they are having problems once they get home.

"We are supportive of the initiative but think there just has to be care that there is flexibility," Sobel said. "The benefits of breast-feeding are undeniable. It's just a matter of going about it the right way. But at the same time we want to make sure parents are making the right choice for themselves."

Greater Baltimore Medical Center is also looking to stop giving out samples.

"It's like we're saying we think it's all right, and we don't want to give that impression," said Marla Newmark, GBMC's lactation coordinator. The hospital has lactation programs in which mothers who breast-feed are seen by a specialist every day in the hospital after giving birth. There are also classes and a warm line.

Most Maryland hospitals are practicing some or much of what the state is recommending, but Phillips said there is much room for improvement.

"I don't know any hospital that meets all the criteria," Phillips said. "Some meet some of them and some is better than none at all. But we can do better."

Mercy Medical Center in Baltimore trains all the nurses who work with mothers about breast-feeding and offers support groups. Mercy's lactation consultants visit physician offices to make sure their message is being passed on during women's doctor's appointments. Nurses also call mothers two weeks, six weeks and six months after they give birth to talk about breast-feeding.

"We want to give them support, and we want to encourage them," said Michele Schwarzmann, Mercy's director of maternal child health. "The literature has shown women are successful at breast-feeding when they have support."

Jasmine Wilson, 21, gave birth to a baby boy last week at Mercy. She had read about the benefits of breast-feeding and her doctor also told her about them. Fortunately, she was one of the lucky ones who didn't have initial problems.

"He latched on right away," she said.

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