Editor of premier breastfeeding journal: time for critical review of the Baby Friendly Hospital Initiative

Online Reviews Evaluation time for review Inspection Assessment Auditing

It took 40 years from the time that Heliobacter pylori was identified as the cause of stomach ulcers for doctors to acknowledge it. That’s because the conventional wisdom was that acid caused stomach ulcers and the conventional wisdom was so deeply entrenched (entire careers had been staked upon it) and people with ulcers, denied effective treatment, died as a result.

Today’s conventional wisdom is that breastfeeding has major health benefits and that promoting it aggressively through the Ten Steps of The Baby Friendly Hospital Initiative (BFHI) is the key to improving infant health. It has been the conventional wisdom for nearly 30 years despite the fact that there is little evidence that breastfeeding has major health benefits for term babies, copious evidence that aggressive breastfeeding promotion has major risks and no evidence that the BFHI even works in improving breastfeeding rates.

”[T]he 10 steps should not be treated as the equivalent of the Ten Commandments …”

No matter. Entire careers, indeed an entire profession (lactation consultant) have been staked upon promoting the Ten Steps of the BFHI.

That’s why it is remarkable to see Arthur I Eidelman, the editor of the premier breastfeeding journal Breastfeeding Medicine, highlight the need for review of the BFHI in general and the Ten Steps in particular.

I find the author’s use of scare quotes particularly telling:

One cannot argue with the recent “success” of the Baby-Friendly Hospital Initiative (BFHI) that was established in 1992 in response to a call to action for support of breastfeeding by the 45th World Health Assembly…

In 2011, in only two states was there >20% BFHI penetration. In 20 states there were no Baby-Friendly facilities. Seven years later, in 2018, 40% of the birthing facilities in 12 states were certified as Baby-Friendly. Most striking, >1 million births (roughly 25%) of the annual US birth cohort were taking place in such facilities…

But recent studies do not support claims of either safety or effectiveness of the BFHI.

Eidelman does not necessarily agree, but:

Careful reading of the two recent reviews confirms that the authors are demanding the same standards of evidence thatare required for any other care plan, procedure, or medication. What they are more than implying is that the 10 steps should not be treated as the equivalent of the Ten Com-
mandments that were chiseled in stone at Mount Sinai and that each of the steps be evaluated separately for evidence-based conclusions.

He notes:

In fact the WHO itself has acknowledged this and recently published a revised set of guidelines for the 10 steps, modifying among other things its previous restrictive policy as to the use of pacifiers, bottles, and teats.

Although he neglects to mention that these restrictions were put in place without any evidence to back them and have resulted in significant suffering for babies and mothers.

His conclusion is powerful nonetheless:

What is needed in my opinion is not a rigid categorical defense of a magic (holy?) 10 but an intellectually rigid evaluation of the individual steps and their possible various combinations (not necessarily of all 10) that are both safe and efficacious.

There is one issue, though, on which I strongly disagree. Eidelman insists:

The measure of success of any initiative should not be the number of certified institutions per se but the actual breastfeeding rates that will meet our healthy people objectives.

Actually it should be neither since both are measure of process, not outcome. The measure of success of any public health initiative is improvement in health OUTCOMES such as reduction of deaths, reduction of illness and reduction of healthcare spending.

The BFHI and the Ten Steps have been around for nearly 30 years, and with the exception of premature infants, they’ve been unable to demonstrate any improvement in health outcomes at all.

That should be a glaring signal that the conventional wisdom about breastfeeding is wrong.

  • EmbraceYourInnerCrone

    I still don’t understand what is at all baby friendly about:

    YOU MUST BREASTFEED 24/7, You WILL NOT GET ANY OTHER FOOD! IT’S OK IF YOU STARVE/DEHYDATE FOR 3 or 4 or 5 days BECAUSE THAT’S PERFECTLY OK FOR A PERSON WHO WEIGHS A GRAND TOTAL OF 7 POUNDS.

    That’s complete nonsense and the BFHI “rules” are not based on anything any medical professional should be following.

    • Daleth

      Agreed! It’s based on NOTHING. And I hate the whole idea that “if mom’s milk doesn’t come in for 3 to 5 days, that must mean baby doesn’t need anything else for 3 to 5 days, because that’s how our ancestors lived and look, the human race survived!”

      No, dude. Here’s how our ancestors lived: mom rested for 3-5 days, recovering from childbirth, while her sisters, cousins, fellow tribe members, or servants/wet nurses took turns breastfeeding her baby. Then she started breastfeeding around day 4-5. Or did you not realize that the isolated nuclear family is a very recent invention???

    • Merrie

      I feel like it basically presupposes that patient care is one-size-fits-all so if providers have the option of giving formula, they will regardless of parent preference or situation. So the only way to keep them from getting formula is to totally ban it in all situations. Not to give it in situations where it’s suitable, and not give it where there is no reason to.

  • KQ Not Signed In

    My son was born in a BFHI hospital. He was exclusively breastfed for almost a year.

    These things had nothing to do with each other.

    In fact, the hospital made it significantly harder. After a full day of labor and a last minute CS, with me doped up beyond all reason, they refused to help with the baby at all. They shoved him between my breast and the bedrail, with a big fluffy pillow to support, and left us there with me nodding out from pain medication and plain exhaustion. The three days we were in the hospital, I never properly slept for more than a few minutes. I was hallucinating and frantic for any help beyond my also exhausted and overwhelmed husband. They wouldn’t even take him for an hour or two to let me have a solid nap. It remains an experience that leaves me shaken and angry and scared, even eight years later.

    We breastfed exclusively because he had a great latch, I had an ample supply, and it worked the best for us. He didn’t have any sensitivities, I didn’t have any issues beyond the initial discomfort (not pain in my case) and no medications I needed were unsafe for him. It was just plain luck/genetics that meant we had a near effortless breastfeeding experience.

    • Madtowngirl

      Agreed. I wanted to BF my first, but it definitely felt like the hospital made everything harder. Hallucinating from painkillers from my C-section, no opportunities to sleep/recover, and the insane shaming from the lactation consultants, and the straight up lying about my baby getting enough milk from me…..I came to resent my baby and dreaded feeding her, and I attribute at least part of that to the cult-like adherence to trying to get me to breastfeed. If someone had given me formula as an option, or even given me a chance to rest and recover from abdominal surgery, maybe I would have been able to at least combination feed.

      I’m not sure if I developed D-MER or what, but the idea of putting my soon-to-be born second baby to my breast makes my skin crawl. We’re going straight to formula.

      • BeatriceC

        I feel like my mother insisting that I use a small amount of formula when I was having issues getting my oldest to latch and stay latched (combination of giant boobs, massive oversupply, and firehose strength letdown) was the only reason why I did eventually breastfeed him exclusively, and the only reason I even tried with the other two. I could have also pumped a little and used that instead of using formula, but the formula was there (hospital goody bag…remember those?) and I was exhausted and her philosophy was to get him fed while we figured things out without making things worse for me, so I could eventually get him on the breast. She was “fed is best” before fed is best was a thing. And it worked. Feeding him a half ounce of formula and allowing my initial letdown to be absorbed into a diaper in my bra made it so he wasn’t so ravenously hungry and was willing to work a little to figure out the latch, and waiting until after the initial letdown made it easier. It only took a couple days of that to get him mostly on the boob and about two weeks to get him fully on the boob and my supply regulated a bit more. And then because it worked out with him, I was willing to try again.

        • demodocus

          Some hospitals still have goody bags, though we only got formula because the NICU nurses sent us home with the rest of the open box.

    • Griffin

      How horrendous. I’m sorry. It makes me so angry to hear how women have been so brutalized in the name of how “women should behave”.

    • JDM

      Wow. To caption the obvious, labelling their actions “baby friendly” is one of the more Orwellian things I’ve heard.