JAMA review questions the safety and effectiveness of the Baby Friendly Hospital Initiative

(Un)Safe - New chalkboard with 3D outlined text

Last week I noted that the editor of premier breastfeeding journal declared that it is time for a critical review of the Baby Friendly Hospital Initiative and its Ten Steps.

The editor’s key point:

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.

Perhaps he was thinking about a new evaluation of the BFHI guidelines that was just published in the Journal of the American Medical Association. The JAMA Network has produced a Clinical Guideline Synopsis of World Health Organization Baby-Friendly Hospital Initiative Guideline and 2018 Implementation Guidance.

The review is couched in careful language, the conclusions devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

The review notes three major revisions in the evidence guidelines [EG]:

1. Recommendations around skin to skin care

The benefit of early skin-to-skin care (SSC) for glucose homeostasis (blood glucose level at 75-100 minutes after birth: meaningful difference, 10.49 mg/dL … 95% CI, 8.39-12.59), thermoregulation (a slight increase in axillary temperature at 90-150 minutes after birth: meaningful difference, 0.30°C; 95% CI, 0.13-0.47), and any breastfeeding at age 1 to 4 months (relative risk [RR], 1.24; 95% CI, 1.07-1.43) was cited. The EG recognizes the potential for sudden infant collapse during unobserved SSC in the first 2 hours of life, citing rates of 1.6 to 5 cases per 100 000 live births with mortality rates of 0 to 1.1 per 100000 livebirths. This is addressed by a recommendation for close observation for at least the first 2 hours after delivery coupled with vigilance to assess and manage signs of distress and prevent the infant from being hurt unintentionally.

Previous BFHI guidelines recommended continuing the practice of SSC throughout the hospital stay while rooming-in. As there are no studies that specifically demonstrate that SSC confers benefits beyond the early hours of life in term newborns, this practice, when coupled with rigid compliance with breastfeeding exclusivity, has raised safety concerns about unmonitored SSC, particularly overnight by an exhausted or sedated mother. The new guideline focuses on immediate (within 10 minutes of birth) and early SSC (10 minutes-23 hours) without explicitly advocating for ongoing SSC beyond that time. It notes the need for safety vigilance during SSC and that hospital resources may be inadequate to safely perform the task beyond the immediate period. The EG also notes that while there are many benefits to rooming-in, many mothers prefer not to and rooming-in “probably makes little to no difference to any breastfeeding at 6 months”.

Take home messages:

  • There is no evidence of benefit of skin-to-skin in term babies beyond the early hours.
  • Even those benefits are trivial.
  • Unmonitored SSC increases the risk of neonatal death.
  • Rooming in makes essentially no difference to breastfeeding at 6 months.

2. Formula supplementation

While supportive of breastfeeding exclusivity, the IG [Implementation Guidance] recognizes that supplementation may be necessary for some infants because of inadequate milk supply and maternal choice. The IG mentions the need for vigilance for the risk for late preterm newborns of jaundice, hypoglycemia, and feeding problems. The EG also cites a Cochrane review of randomized controlled trials demonstrating that “addition of artificial milk in the first few days after birth probably makes little or no difference to the success and duration of breastfeeding at discharge” (RR, 1.02; 95% CI, 0.97-1.08) and the IG national monitoring definition of exclusive breastfeeding is now receiving “only breastmilk during the previous day.” A recommendation was also added to provide donor milk to healthy full-term newborns who required supplementation without providing cost-benefit evidence to support this practice in term infants.

Take home messages:

  • Formula use may be necessary because of inadequate milk supply.
  • There is no evidence that judicious formula use in the first few days has any impact on breastfeeding.
  • There is no evidence to support a recommendation of donor breast milk for term infants.

3. Pacifier use

Consistent with evidence that pacifiers reduce the risk of sudden infant death syndrome (SIDS) and high-QOE that pacifiers do not interfere with breastfeeding outcomes, the draft IG had pro- posed eliminating pacifier restrictions. Despite evidence that mothers value using pacifiers, this change was not included in the final IG. Instead, advice to counsel mothers about hygiene risks was added without mentioning the reduced risk of SIDS associated with pacifier use.

Take home messages:

  • Pacifiers prevent SIDS.
  • Pacifiers do not interfere with breastfeeding.
  • The new guidance ignores this scientific evidence.

The authors note that the BFHI is not the only way or even the best way to support breastfeeding:

Institutional and public health clinicians should consider using the EG to develop their own policies whenever a specific recommendation in the IG is inconsistent with evidence or does not seem applicable to local circumstances.

A notable shift of emphasis that will foster local innovation is the IG conclusion that BFHI designation is not the only worthy public policy option for breast feeding support. Consistent with the US Preventative Services Task Force evidence report, the draft for public comment stated “While the designation of baby-friendly is one way to recognize facilities that provide appropriate care, designation is not the most effective strategy to achieve sustainable improvement in the quality of maternity care.”

Though the review is couched in careful language, the conclusions are devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

  • fiftyfifty1

    And here’s perhaps the MOST important point that got hidden in the middle of a big paragraph:

    “The IG national monitoring definition of exclusive breastfeeding is now receiving ‘only breastmilk during the previous day.'”

    It’s about time!!! Finally an end to this purity obsession! Finally an end to the “just one sip of formula ever means your baby is not exclusively breastfed.” No more obsession with “virgin gut” and all that other bullshit. If your baby had nothing but breastmilk all yesterday, your baby is experiencing exclusive breastfeeding.

    • The Bofa on the Sofa

      I kind of got a kick out of that. So they re-define exclusive breastfeeding to not require that the baby be exclusively breastfed. But we’ll still call it exclusive breastfeeding, because, you know, that sounds more impressive or something.

      • fiftyfifty1

        I don’t think they changed the definition to try to impress anyone. They redefined exclusive breastfeeding to take the incentive off of hospitals to send out dehydrated babies just to raise their exclusive breastfeeding numbers. It means that you can now supplement your baby a bit before your milk comes in without being told you ruined it forever. When we measure “exclusive breastfeeding” in my opinion, it should not be some ridiculous insistence on not one drop of formula ever. It should mean that on a typical day (say yesterday) your baby is fed with 100% breastmilk.

        • RudyTooty

          ” to take the incentive off of hospitals to send out dehydrated babies just to raise their exclusive breastfeeding numbers ”

          ^THIS.

  • rational thinker

    The BFHI certainly does lack common sense. I had both my kids at two different hospitals my first baby was at a BFHI hospital. I had a rough delivery 24 hrs of back labor the last two hours of it pushing. I had my son at 10:58 pm then I don’t remember how long it took to stich me up I had fourth degree tears. I know they had a nursery but it looked like they just used it to store crap and it was always dark in there. Later a nurse told me they weren’t allowed to use it and that all babies had to room in with mom and I would have to care for baby my whole stay.. After I was finally able to go to sleep I woke up cause my son started crying it was an ordeal even to get out of bed but I had to cause I had to take care of my own baby. So I got up and got to the baby then two min later I looked at the floor and it looked like someone had been murdered in my room there was blood everywhere. So I had to call a nurse at that point. She had to mop up the floor help me with the baby and clean me up too and It was the middle of the night. I felt bad about this then she told me this should not have even happened its because of new policies and not being allowed to use the nursery. So that whole incident could have been avoided if they had a nursery. By morning when new shift came on they wouldn’t help me with anything and I couldn’t move easily and they just kept telling me not to complain cause a c section is so much worse and I was only 17 at the time so I belived them. Now I know better. My second child was born at a different hospital that was not BFHI. That was a much better place and they treated me like a human being and not a baby factory. Most of the stories I hear about them are not good. I am glad people are starting to realize it.

    • MaineJen

      Dude. I would take a c section over 4th degree tears any day of the week. That sounds horrible.

      • rational thinker

        I think the tearing was so bad cause he was almost 2 weeks overdue. When I told the nurse the next day that it was hurting a lot she got very snobby and told me how lucky I was that I had a vaginal birth, then she told me that the lady in the next room had a C-section so if anyone was in pain it would be her.

        • space_upstairs

          And I wouldn’t be surprised if they told the C-section lady something like: “If you’d done everything right (gained less, weighed less at the start, been younger, not thought negative thoughts, etc.) you wouldn’t have needed a C-section. Suck it up and keep your baby on your boob so as not to screw up anything else.”

        • MaineJen

          Um….I’m thinking that 4th degree tearing might actually require MORE stitches than a c section. And in a much more sensitive area.

        • RudyTooty

          People like the nurse you had shouldn’t be working with … PEOPLE. What a lack of compassion! I’m sorry.

          • rational thinker

            At least they didn’t yell at me for formula feeding I did have to sign that stupid form though.

        • BeatriceC

          I had a traumatic vaginal delivery and two c-sections, one of which was a “smash and grab” style CS, and the recovery for even that one was orders of magnitude easier than the traumatic vaginal delivery.

        • PeggySue

          Apparently this nurse had not actually eyeballed the areas with sutures…

          • rational thinker

            no one checked on it after the doctor was done stitching. They usually put you in those net underwear with the big absorbent pad but I don’t know why they didn’t they let me go to sleep without putting the underwear on me. so when I got up I bled out all over the floor.

  • PeggySue

    In the last italicized paragraph, beginning with A notable shift of emphasis, the word “Preventaive” should be “Preventative.”

    Also, I am really glad some of this bunk is being addressed.

    • Amy Tuteur, MD

      Fixed it! It was misspelled in the original.

  • MaineJen

    The word “essentially” is misspelled at the end of point 1.

    So glad to see these new guidelines. MAYBE we can get some well baby nurseries back??

    • Amy Tuteur, MD

      Thanks! Fixed it.

    • Christine O’Hare

      I sure hope so – the lack of well baby nurseries is appalling and going to be a major factor in determining where I give birth to my next child.

      • MaineJen

        I had relatively uncomplicated deliveries, and it was STILL rough to be left alone in the middle of the night with a new baby, tired, sore, and with no idea what I was doing! On our second night there I had to send my son to the nursery for a few hours because I was exhausted…this was nine years ago, when there still WERE nurseries.

        I can’t imagine having just had a traumatic delivery, or a c section where you are told “Don’t lift anything heavy!”, and then being left alone with baby. If you can’t move yourself around easily, how are you going to lift the baby, change diapers, or breastfeed all by your lonesome?

        The answer, of course, is either to bring back well baby nurseries, or provide MORE NURSES in the postpartum ward. But the bean counters don’t want to hear that.

        • AirPlant

          I am not saying your answer is wrong but my full expectation is that the answer that I will be given is “you are a mother now, don’t ask for someone else to do your job”

          • MaineJen

            *sigh* Yes. I agree. Completely ignoring the fact that, throughout history, women always had multiple people around them to help with the baby! Because *of course* you didn’t leave a new mother alone after delivery, that would be silly right?? SMH

        • Ozlsn

          Some friends and I were skyping with a Malaysian Chinese friend who is expecting her first child. We were chatting about preparations and she said “I’m interviewing my confinement lady tomorrow”. Hang on, we said, your what?
          “Oh it’s the woman who comes in and does all the cooking and the night feeds so the mother can rest and recover for the first 28 days.”

          Why is this not a thing here?!? Actually given the increasing population of Chinese descent here I suspect it will become so in the next decade or so, but in the meantime you guys get confinement ladies and we get the BFHI?!?

          • namaste

            Because we can’t POSSIBLY delegate responsibility to anyone else! Otherwise, we will still have *gasp* an identity outside of mothering, we won’t become propper mummy martyrs, civilization will collapse, and the sun will go supernova.

          • space_upstairs

            Rugged individualism: if you can’t do it yourself you’re un-American.

          • Cristina

            I want a confinement lady. I’m not pregnant, I just want someone else to deal with everything for a month.

          • rational thinker

            this is an awesome idea they should overthrow the BFHI and implement this.

          • Anna

            In the past it would have been your Mum. Its very common in Japan still for women to go home to their parents home after birth and some women even travel to their home town to give birth if its far away. These days its becoming more common for Mum to come and stay or even MILs to chip in, though Japanese MILs are notorious for bullying their DILs so case by case. My Mum is way more useful than hubby. Hes gonna have the first week off, which will be at least 3 days in hospital, then Mum will be here the second. Big kids will be off school so she’ll take them all out to play and I bet she wont be feeding them takeaways and I wont find a trashed house. I’ll get fed and fussed over.

          • Who?

            My parents came when our second was born, it was lovely for everyone: big boy got looked after, house and meals taken care of, and I got ‘fed and fussed over’. Ideal if it all works out.

            We’ve just had three months in Japan, it is a bit rare to hear a mother-in-law say anything nice about daughter-in-law. It can be a difficult relationship, no doubt.

            Good luck with the baby!

      • seenthelight

        I’m so thankful for this place, because I found it while pregnant with my second and so HELD FIRM when my nurse that first night didn’t want to take baby to the nursery. She tried to negotiate about at least bringing baby back to breastfeed and I laughed and said my milk isn’t in yet anyway, give baby formula, I’m going to sleep, thanks. It felt good. Both to tell the nurse to shove off and to sleeeeep.

  • Cartman36

    This is awesome BTW. I am so glad to see some organizations finally holding BFHI accountable

  • Cartman36

    I wish I had the email address of the OB nurse supervisor I spoke too after my last delivery that was “shocked” I would think that they closed the well baby nursery as a cost savings measure and couldn’t believe none of the nurses warned me against co-sleeping when I was so exhausted the first night that I kept him in my bed. I would love to send her this.

    • Sarah

      You could probably get it you know!