The Baby Friendly Hospital Initiative is a moral failure

epic fail wooden letterpress

I’ve argued repeatedly in the past that aggressive breastfeeding promotion in general and the Baby Friendly Hospital Initiative in particular are scientific failures. They ignore the scientific evidence in favor of the personal beliefs of lactation professionals — exaggerating the benefits of breastfeeding, hiding the risks (dehydration, jaundice, brain injures and deaths) and demonizing pacifiers and judicious formula supplementation as harmful when in fact they are lifesaving.

But aggressive breastfeeding promotion, particularly the Baby Friendly Hospital Initiative is also a moral failure. A new paper in Current Sociology, Social roles and alienation: Breastfeeding promotion and early motherhood, explains:

…The article argues that the effort to rigidly impose a moral code as the role [of mothering] is taken on has potentially alienating effects, as it limits the scope for the agent to appropriate and identify with it. An approach to health promotion which instead trusts women to exercise situated moral judgement about infant care, rather than subjecting them to an externally imposed moral code, would reduce the emotional strain and potential for alienation in early motherhood.

The Baby Friendly Hospital Initiative treats women not as ethically valuable in themselves but instead as the means for achieving breastfeeding targets.

Our views about motherhood have recently undergone substantial change:

Motherhood has undergone significant transformation in recent decades, as the expectation of individual autonomy has reshaped gender and family life. Women now expect to become mothers not because of biological destiny, coercion, or social duty, but instead as an aspect of a self-directed life. Motherhood is expected to be taken on only when it is understood as integral to the agent’s realization of her intentions and values.

At the same time, the practices of mothering, particularly in the early stages, have become the focus of intense public interest. Cultural ambiguity about the value of full-time mothering has shifted public debates away from the question of whether mothers should engage in paid employment at all, to a focus on the quality of maternal caregiving.

As a result:

Time-intensive mothering practices, especially breastfeeding, have become an important focus of status claims for both stay-at-home and employed mothers.

Ironically, at the same moment that women have been freed from the expectation to have children for no better reason than because it is their biological destiny and therefore must be best, women who choose to have children are still prisoners of the expectation they will breastfeed because it is their biological destiny and therefore must be best.

It’s hardly surprising then that so many good mothers feel so bad about breastfeeding:

Breastfeeding tends to be experienced as emotionally intense, in positive and negative ways. Sustained breastfeeding is generally understood to depend on self-control, in the form of maternal self-sacrifice and concentrated effort, if it is to be ‘successful’. Most women are fully aware of the message that ‘breast is best’, but tend to act in ways which take account of various other considerations.

Then they are shamed for daring to take other considerations into account.

The expectation that good mothers will breastfeed is a feature of the Baby Friendly Initiative. This is a programme for promoting breastfeeding as ‘the golden standard of care’ in maternity centres and amongst health professionals caring for mothers and infants following birth…

Women have not been imagined as decision-makers in this initiative, but instead as passive recipients of information, training and support.

That is a serious moral defect:

Health promotion strategies like this tend to assume that target populations are likely to comply with moral pressure. Such behaviourist expectations take little account of human agency, autonomy, or the indeterminacy of the social world… Such utilitarianism treats agents not as ethically valuable in themselves but instead as the means for achieving public health targets.

In other words, women are treated as objects to be acted upon, not as individuals capable of making their own decisions.

What’s the harm?

When pressure is brought to bear on women to breastfeed in the first hours, days and weeks after giving birth, the role becomes rigidly defined. This undermines agency, the ability to ‘take and make’ motherhood, developing some command over the role through interpretation and improvisation.

That accounts for the plethora of recent articles in which women detail how they and their babies suffered under pressure to breastfeed. It also accounts for the popularity of the Fed Is Best movement; not only is being fully fed with formula better for babies than starving on breastmilk, using formula to ease the stress of new motherhood is better for mothers than struggling to breastfeed.

Even breastfeeding professionals have been forced to address women’s suffering, but sadly they interpret it through the lens of breastfeeding promotion. They’ve defined breastfeeding “trauma” as the disappointment of being unable to breastfeed when the reality is that breastfeeding trauma is a result of treating women as merely the means to reach breastfeeding targets, instead of compassionately as individuals with their own needs, desires and moral agency.

Her baby, her body, her breasts, her choice!

  • Georgie

    Thank you so much for this. I planned on breastfeeding, but had latching problems from the beginning and my milk never really came in. My baby lost 10% of her body weight by day 4, had urate crystals in her diaper (and not enough fully wet diapers) and worsening jaundice. I was devastated when I was told to give her formula. I had stared at the BFHI poster on the wall in my hospital room and thought I needed to exclusively breast-feed for 6 months in order to be a proper mom. I saw numerous lactation consultants who shamed me and tried to tell me that insufficient breastmilk is exceedingly rare and that I wasn’t stimulating my breasts enough. I tried for 5 months, breastfeeding, formula feeding and pumping every 2-3 hours. I was suicidal because I thought I was failing my baby if I couldn’t get this basic fundamental thing right. I’m still struggling with obsessive thinking about breastfeeding and doubt that I am a good mom.

    • Desiree Scorcia

      I’m so sorry to hear that you’re still struggling. Are you seeing a therapist? My therapist and zoloft are my lifelines.
      Also, you’re a GREAT mom!! You did what was hard and unselfish because it was the best thing for your baby. I’m so sorry for all the b.s. about breastfeeding and how much it hurt you. Take care of yourself!!!

      • Georgie

        Thank you. Yes, I am getting help.

    • Emilie Bishop

      I’m so sorry for the struggles you and your baby had. We had similar ones and they cast a dark shadow over my son’s whole first year of life. I hope you continue reading this blog and the Fed is Best Foundation’s blog if you haven’t. You’ll feel much less alone because you’ll see how many women and babies have been down the same path. Whether you believe it now or not, know that none of it is your fault. The hospitals set moms up to fail.

      • Georgie

        Thank you. I know now that BFing is overrated and its benefits are exaggerated. My baby is now over 1 year old and has only had one ear infection and a runny nose every few weeks. I wish I could stop obsessing over the BFing though. I still don’t understand why I couldn’t produce enough. I hope this BFHI goes away and that we are no longer subjected to all this aggressive BFing promotion.

        • Cartman36

          Have you read Joan Wolf’s book “Is Breast Best”? If not, please do. It was a slow read for me because its more textbookish than I am used to but I plugged away and read it cover to cover. I haven’t felt a smidgen of guilt about how long I breastfed since.

    • RudyTooty

      I really wish being “devastated” for feeding one’s baby formula WAS NOT A THING.

      And I know you are not the only mother who has felt this way. And I know that devastated is not too strong of a word for it.

      Mothers receive the message that if they don’t feel devastated, then they are emotionally deficient or flawed in some way. Feeling guilty for feeding formula is buying into the lactivist idea – if you don’t feel guilty, you haven’t bought into the propaganda, you don’t want magical, mystical health benefits for your baby, and you’re just an all-around shit mom.

      Lactivists, natural childbirth nuts, midwives…. they all need to own this bullshit. They’re the ones promoting it. This ideology harms people.

    • demodocus

      I hear you, my eldest also lost that much, by day 3. Turns out I don’t get much colostrum at all and my milk doesn’t come in for 5 days. The thought of bfing my youngest made me suicidal, and then the guilt about “not best” sigh.

    • Madtowngirl

      I’m so sorry. Your story mirrors mine so closely – the weight loss, the urate crystals…. I remember laying on the kitchen floor telling my husband I wanted to die because I failed at breastfeeding. I hate that there are so many of us out there with similar stories. I’ve said it before, and I’ll say it again, the BFHI needs to die in a fire.

  • Lisa

    “Women now expect to become mothers not because of biological destiny,
    coercion, or social duty, but instead as an aspect of a self-directed
    life. Motherhood is expected to be taken on only when it is understood
    as integral to the agent’s realization of her intentions and values.”
    Except where I live, young Moms have babies because: A) They didn’t want to be seen as a slut for being “prepared” and having birth control in their purse; 2) They won’t go to Planned Parenthood because ‘people will thing I’m getting an abortion,’ 3) They got drunk/high/stoned, or boy friend was drunk/high/stoned and while they wouldn’t call it ‘rape’ he was extremely demanding. 4) They actually got pills but got mad at boy friend and quit taking them, then reconciled but forgot to say they’d stopped the pills, 5) Because ‘but we ARE in committed relationship–aren’t we, Babe? And, I don’t want anything between us,’ and all the other bull shit lines ever used. And by young, I mean anywhere from 14 to 25–they don’t go to college, barely cared in high school, Grandma is likely under 45!

    What gets me about all this is how ENTITLED and PRIVILEGED it all is. Rural white girls aren’t going to breast feed for very long—-to get welfare they have to take job. You don’t get a “pumping room” or a break for it when you work in a warehouse or a gas station. Forumula is covered by WIC and then someone caring for the baby while Mom is working (or stoned or away with new boy friend) can actually feed the child. FEEDING matters. These are young people who will get diapers from food banks, blow dry wet diapers with a hairdrier to reuse them. They aren’t going to give a shit about “bonding”. The whole Breast is Best and Baby Friendly thing and ridiculous Attachment Parenting is an middle/upper-middle class thing PERIOD. A mother not doing those things is not a cause to call in CPS. The complete disregard for the cultural norms of people without Phds (or even without a B.A./B.S. degree) and not in a while collared profession is akin to virtue signalling. The sanctimonious drivel they bombard girls with in the hospital is about as forceful as going to an anti-abortion “crisis” pregnancy center.

    It’ ticks me off as you probably gathered.

    • fiftyfifty1

      It’s a pity about the stigma surrounding Planned Parenthood, because this is the demographic that does great with Long Acting Reversible Contraceptives (LARCs) like Nexplanon and IUDs. I hope, at least, that regular doctor offices in your area will put them in.

    • Sarah

      One sees similar disregard for the cultural norms of white working class people in the UK. Probably a large part of the reason why breastfeeding promotion amongst the community has been such a hard fail.

      I’m reminded of some funding cuts in my area at a community centre a few years back. The well attended drop in playgroup sessions were cut, but the money for the sparsely used breastfeeding café remained. This did not go unnoticed amongst local women.

    • RudyTooty

      Yes. To all of this.

  • fiftyfifty1

    I love these posts where you report on the work of academic philosophers, ethicists, feminists and sociologists. The standard discourse out there promoting NCB and lactivism is just so loud and dominating even within Medicine (which should know better.) It’s like BREAST IS BEST, THE CS RATE IS TOO HIGH, NATURAL IS BETTER is getting shouted by the dominant culture. Yet there has always been this quiet trickle of voices saying “no, this isn’t ethical.” It’s so heartening that these voices exist. Thanks for finding these voices and giving them a wider audience.

    • demodocus

      I hate it when the lunatic fringe comes to dominate any area.

    • RudyTooty

      Yes. I appreciate hearing an alternative to the standard discourse.

      Yet – this NY Times story arrived (uncritically) in an email from ACOG this morning.

      It feels like one step forward, two steps back.

      So tired of this narrative surrounding natural birth.

      Why New York Lags So Far Behind on Natural Childbirth
      https://nyti.ms/2zx6Ci7?smid=nytcore-ios-share

      • Amy Tuteur, MD

        I left a comment:

        “It is mind boggling that anyone could write about the difference between birth centers in NY and Texas and leave out the single most important fact: Texas allows the practice of a second, inferior class of midwife (CPM/LM/lay midwife) who does not meet the international standards met by ALL other midwives in the industrialized world.

        This second class of midwife is not allowed to practice in hospitals and therefore they open birth centers. As a recent Gatehouse Media investigation revealed, these midwives often practice illegally, ignore risk guidelines, and have a much higher neonatal death rate than real midwives (certified nurse midwives).

        It’s easy to have more birth centers when you have low standards. That’s not an achievement; it’s a scandal.”