The Baby Friendly Hospital Initiative is coercive and violates women’s medical autonomy


The American College of Obstetrician Gynecologists Committee on Ethics recently issued an important position paper entitled Refusal of Medically Recommended Treatment During Pregnancy. Their most important conclusion is this:

Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.

I agree completely, but I have one question. When will ACOG condemn the Baby Friendly Hospital Initiative for its coercive approach to breastfeeding?

[pullquote align=”right” cite=”” link=”” color=”#FD842B” class=”” size=””]The Baby Friendly Hospital Initiative represents a deliberate and fundamental assault on women’s bodily autonomy.[/pullquote]

The BFHI — whose cornerstones include forced lectures on the benefits of breastfeeding, prohibitions on formula supplementation and pacifiers, and mandated 24/7 rooming in of babies  — is profoundly (and proudly) coercive, violating patient rights, respect for women’s autonomy, power differentials and gender equality.

The ACOG opinion brilliantly lays out the issues and principles at stake. These issues and principles apply equally to breastfeeding, another medically recommended treatment. Among them:

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

Breastfeeding is also not an exception to the principle that a decisionally capable patient has the right to refuse to medical recommendations. Therefore her decision should be respected.

The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge… Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

The use of coercion to promote breastfeeding is also ethically impermissible as well as medically inadvisable because of the realities of prognostic uncertainty as well as the limitations to the benefits of exclusive breastfeeding. Lactation consultants, nurses and physicians should be discouraged in the strongest possible terms from use of duress, manipulation or coercion to motivate a woman to breastfeed.

Forced lectures on the benefits of breastfeeding, forced visits by lactation consultants, and prohibition of formula supplementation and pacifiers represent both coercion and duress. The closing of well baby nurseries, justified by the desire to promote breastfeeding, represents duress, manipulation and blatant coercion.

Eliciting the patient’s reasoning, lived experience, and values is critically important when engaging with a pregnant woman who refuses an intervention that the obstetrician–gynecologist judges to be medically indicated for her well-being, her fetus’s well-being, or both…

Respect for a patient’s reasoning, lived experience and values is critical to engaging with a woman who cannot or does not want to breastfeed. When a woman tells you that she does not want to breastfeed, that decision should be respected, not viewed as an opportunity to change her mind.

It is not ethically defensible to evoke conscience as a justification to attempt to coerce a patient into accepting care that she does not desire.

There is no ethical justification for most of the principles of The Baby Friendly Hospital Initiative. Indeed, there is less justification for coercive treatment around breastfeeding, which has only small benefits for term babies, than there is for coercive treatment around medically recommended procedures designed to save a baby’s life or brain function, like C-sections.

The Baby Friendly Hospital Initiative represents a deliberate and fundamental assault on women’s bodily autonomy, and as such is deeply sexist. Men have the right to control their reproductive organs free from interference by governments, hospitals and providers. Women are entitled to the exact same right and the fact that the BFHI treats women and their breasts as if they constitute an exception to basic principles of patients’ rights is deeply disconcerting.

That’s why the rush to close well baby nurseries is profoundly unethical. Not only is it bad for babies because it increases the risk of in hospital deaths from falling out of bed or being smothered; not only is it bad for mothers because it keeps them from getting the sleep they desperately need to heal from labor and birth; but it is unethical because it is a deliberate effort to coerce women into 24 hour rooming in against what they might actually wish.

The truth is that there is nothing special about breastfeeding. It isn’t life saving for term babies and its benefits are trivial — a few less colds and episodes of diarrheal illness across the entire population of infants in the first year. If women have the absolute right to an informed refusal of a potentially life saving C-section — and they do — they most certainly have the right to opt out of every single provision of the BFHI.

The Baby Friendly Hospital is deliberately both manipulative and coercive. It depends on power differentials, violates women’s’ fundamental right to bodily autonomy, and is deeply sexist because it treats women’s bodies differently than men’s bodies.

ACOG is absolutely right that it is ethically indefensible to coerce women into accepting obstetric care that they do not desire. Will they affirm the fact that it is equally indefensible to coerce women into breastfeeding?