The tragedy of the Baby Friendly Hospital Initiative can be explained by Goodhart’s Law

Performance target

I wrote a piece that appeared on Slate on Friday. Will the Tide Ever Turn on Breastfeeding? highlights the fact that most of the promised benefits of breastfeeding have never appeared. Worse, aggressive breastfeeding promotion is harmful.

There has been an increase in babies falling from their mothers’ hospital beds or suffocating [due to forced rooming in]. There has been a rise in serious harms to babies including dehydration, starvation, brain injuries, and even deaths. Indeed, exclusive breastfeeding on discharge is now the leading risk factor for hospital re-admission.

Nearly all the pain, suffering and death can be traced to the Ten Steps of the Baby Friendly Hospital Iniative. How could lactation professionals, good people with good intentions, turn out to be so wrong? As I explained in the Slate piece, health recommendations were issued on the basis of small studies without waiting for confirmation by larger studies. Most of these early studies have been debunked. Moreover, small studies, by their very nature, cannot reveal the risks that become serious problems in large population.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When a measure becomes a target, it ceases to be a good measure.[/pullquote]

The tragedy of the Baby Friendly Hospital Initiative is that a program designed to improve babies’ health has harmed them instead; tens of thousands of newborns are readmitted to the hospital each year for dehydration and jaundice. Equally tragic, a program designed to support mothers has ended up undermining their psychological health.

Why? The answer can be found in data science: Goodhart’s Law.

When a measure becomes a target, it ceases to be a good measure.

Campbell’s Law, a corollary of Goodhart’s Law, is equally instructive:

The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.

What does that mean?

Incentive structures work,” as Steve Jobs put it. “So you have to be very careful of what you incent people to do, because various incentive structures create all sorts of consequences that you can’t anticipate.” Sam Altman, president of Y Combinator, echoes Jobs’s words of caution: “It really is true that the company will build whatever the CEO decides to measure.”

This sketch from the fantastic website Sketchplanations illustrates the problem:

B3A02E02-D413-46B1-B330-D763944AACD4

Imagine you are the CEO of a company that manufactures nails and you want to incentivize your workforce to increase profits by rewarding them for meeting production targets.

If you tell them you will offer a bonus to workers who meet a target number of nails produced each week, workers will start making tiny nails so they can produce more of them. If instead you offer a bonus to workers who meet a target for weight of nails produced each week, workers will switch to producing a few massive nails. When a measure becomes a target, it ceases to be a good measure because setting a target distorts and corrupts the process it is designed to monitor.

What should the CEO of the nail factory have chosen to measure?

Data scientist Roman Shraga offers this answer:

You need to ask questions that ensure the measure relate [sic] to the ultimate goal. Additionally, think about whether it would be possible to get a perfect score on the measure, and if it would be possible, to do so without adding any value. This line of reasoning will allow you dissect a measure until you understand whether or not it is doing a good job of indicating performance.

In other words, the CEO should have chosen a measure, or a combination of measures that increases productivity without compromising quality.

Now let’s look at the Baby Friendly Hospital Initiative. Its leaders chose to incentivize hospitals, nurses and lactation consultants on exclusive breastfeeding rates at discharge. That seemed like a good target to choose because the goal was to increase long term exclusive breastfeeding rates and the mothers who breastfeed exclusively for the long term are likely to be exclusively breastfeeding at discharge. In addition, it is much easier to measure exclusive breastfeeding rates at discharge than to track down mothers and babies to see if they are breastfeeding 3, 6 or 12 months later.

How has this target distorted and corrupted the provision of breastfeeding support to new mothers? Just look at the Ten Steps:

9FDF92F0-05A2-4943-8073-C1C2AB436A8C

Since hospitals, nurses and lactation consultants want to maximize the rate of exclusive breastfeeding at discharge, the Ten Steps make it nearly impossible to avoid breastfeeding. Mothers are hectored to breastfeed, forced to breastfeed within the first hour, denied formula, forced to endure the baby’s cries of hunger by rooming in, and denied pacifiers that might soothe the baby.

When lactation consultants are incentivized to maximize rates of exclusive breastfeeding at discharge, they ignore dehydration, hypoglycemia (low blood sugar) and jaundice because treating them would involve formula and that would reduce the rate of exclusive breastfeeding.

When lactation consultants are incentivized to maximize rates of exclusive breastfeeding at discharge, they make formula hard to get: they restrict access to it, lock it up and force women to sign odious, shaming “consent forms” to get it.

When lactation consultants are incentivized to maximize rates of exclusive breastfeeding at discharge they make sure that hospital personnel will not have to endure the anguished cries of starving infants by closing well baby nurses and leaving babies in mother’s rooms around the clock. And should nurses break down because of simple human compassion and offer formula, they are excoriated by official policy.

Is it any wonder then that exclusive breastfeeding has become the leading risk factor for hospital readmission? By setting the wrong target, the BFHI incentivizes poor, even deadly, care.

What should breastfeeding promotion incentivize?

Since our goal ought to be providing breastfeeding support for anyone who wishes to breastfeed:

1. Mothers’ desires must be accommodated, instead of ignored as they are now.

2. The quality, availability and accessibility of SUPPORT should be measured not the absolute number of infants breastfeeding exclusively.

3. Hospital readmissions must be measured since any effort to promote breastfeeding that leads to an increase in dehydration, hypoglycemia and jaundice is a failure regardless of how high the rate of exclusive breastfeeding at discharge might be.

4. Formula should be easily available; women should be taught how to use it; and judicious formula supplementation should be freely recommended in the early days when babies are most likely to suffer breastfeeding complications.

5. The only breastfeeding rates that are clinically relevant are rates beyond two months. That’s much harder to measure but that’s what actually matters. Measuring exclusive breastfeeding rates on discharge reflects the streetlight effect, also known as the drunkard’s search principle: searching for keys lost in a unlit park under a streetlight because that where it is easiest to look.

The tragedy of the Baby Friendly Hospital Initiative is that bad outcomes were nearly guaranteed by focusing on the wrong target … and failing to understand Goodhart’s Law: when a measure becomes a target, it ceases to be a good measure.

  • Glia

    This is a really, really good point. I’ve been thinking a lot about exclusive breastfeeding as a goal. With my first kid, I managed EBF, but I consider it not a great thing, because it made him miserable before my milk came in, and I think that he would have been more satisfied (and we’d all have gotten more sleep) if I’d supplemented after I went back to work.

    With my second, I supplemented before my milk came in. It was probably a total of 2 oz or less over the first week. She’s over a year now, and she’s still breastfeeding. She never had another drop of formula after that first week. I even ended up giving away most of the formula I’d bought for her, because we just didn’t need it. But my hospital was BFHI, so that means that somewhere, she and I were counted as a breastfeeding “failure”, because she had formula while we were at the hospital. I saw several LCs, and actually, they were all great, very interested in making sure that our goals were met, never discouraged supplementing. I am positive that if I told any of them about my daughter, they would consider us a BF success. But, that little bit of formula, that tiny fraction of a percent of the milk she’s had, is apparently the only thing that matters. It is absolutely nonsensical.

  • rational thinker

    Insurance companies could be taking preventative measures themselves against the BFHI. Insurance companies are now required to provide new moms with a breast pump with a price tag of around $400. Newborn readmissions for dehydration/starvation can cost anywhere around one hundred thousand. (I am not sure of exact amount) If mom is already getting a pump then they should also provide an infant scale. (most basic ones are around $30 on amazon) Most moms are told by the lactation professionals that cluster feeding is normal and not to worry about baby not getting enough and all moms can breastfeed and produce enough. My point is that while lactivist’s lie scales do not. If mom could weigh her baby at home after each feed she could see for herself that baby is not getting enough and start supplementing right away instead of being told “Just keep breastfeeding” and following bad advice. Simply by having a scale that could reduce the number of readmissions and save a lot of money and more importantly lives and brain function of babies. If they did start giving scales to new moms the breastfeeding industry would probably complain the same way they complained about the milk screen product.

    • Who?

      This is a good point-a set of scales would cost a fraction of $400 and a few minutes of tutorial on how to use them.

      But, as you say, it would ruin the narrative a little.

  • namaste

    I’m a psychotherapist by trade, a Clinical Social Worker. I specialize with kids with some serious behavioral difficulties. I see kids who are on the spectrum, kids who are probably headed for Juvie, kids who are severely depressed, and everything in between. You better believe that when conducting a psychosocial history for an intake, I have asked each and every parent who has walked through my door if their kids were breastfed or not. Oh…….wait……

    • I am curious: What are the commonest ways parents respond badly to their kids’ difficulties? Turning a blind eye to them, “treating” issues with quackery, punitive treatment, overindulgence, or what?

      • MaineJen

        I’m curious too…as the parent of a kid who I’m pretty sure has inherited my depressive tendencies along with an explosive temper…what would be the RIGHT way to respond? LOL.

        It’s a hard balance to achieve, between overindulging/rewarding bad behavior, and not responding to serious clinical issues. I know I’ve responded ‘badly’ in the past, but sometimes it’s hard to know what to do when a kid is screaming/lashing out.

  • PeggySue

    All this measurement is why many competent folks are leaving health care, because either the measurements are contributing to bad outcomes or the measurements have nothing to do with patient well-being.

    • RudyTooty

      Exactly. So much of health care has NOTHING to do with patient well-being. Why stay?

  • TsuDhoNimh

    Readmissions should be taken VERY seriously and the root cause traced.

    And if it was because the mother’s milk was insufficient, and she was discouraged from giving formula by the lactivists, and not told how to measure intake (weighing diapers is the easy way) and when to supplement for the good of the baby, they should have their bonuses yanked back and sent to remedial physiology classes.

    • Azuran

      And then you have the same problem. If you make ‘readmission’ a measure, then people will avoid readmitting and keep patient out of the hospital until they reach a critical point in the hopes that things eventually get better and they avoid the readmission. There is actually currently worries following a few studies that showed that penalties for hospital readmission might actually be hurting patients and causing more deaths.

      • PeggySue

        That has driven some hospice admits from the ED, to be sure; an ED visit can be coded as outpatient, therefore no readmission.

      • Mel

        The one thing that might alleviate this is the fact that L&D/OB-GYN is a completely different department than neonatology/pediatrics. I’m struggling to see how a pediatrician in an outpatient setting or even in an ER is going to be like “Huh, I’ve got a critically ill newborn here – but readmitting them is going to ding our L&D’s metrics. Let’s punt and hope for the best”.

        In a department with an ongoing relationship with a patient like cardiology or…well, pretty much every department outside of L&D / peds…. the doctors will be trying to serve two masters – the good of their patients while dealing with metrics.

        But the L&D team including my OB hasn’t seen my son since delivery. The crazy LC who drove me nuts – I’m not entirely sure the neonatologists knew her name. I know my son’s pediatrician would have readmitted him in a hot minute if he needed it – and I really doubt she would have cared a bit on how it would have affected the L&D metrics.

        • Azuran

          Well, in most cases it’s the hospital who gets the penalty, not necessarily the doctor or department himself. Which means that even if the OB/GYN or whoever else is doing their job properly, if they are costing multiple penalties to the hospital, eventually they are going to have a meeting with administrator where they’ll have to justify all their readmission. Or if you are causing another doctor to have their pay cut off because you readmitted one of their patient, it is going to cause bad blood.
          Everyone is human, even doctors, and this has happened.

      • TsuDhoNimh

        Good point

      • mabelcruet

        In the UK ‘failed discharge’ rates are monitored-thats when a patient is readmitted within a certain time after discharge with the same complaint, but I don’t know if that includes newborns. Technically they weren’t admitted to hospital in the first place, they just apparated on labour ward…

        But the inspectorate bodies who monitor NHS facilities do have targets for failed discharges and hospitals are supposed to investigate why it happened.

  • demodocus

    There’s a fair bit of that in education lately too. Students’ test scores are the basis for all kinds of things (depending on district/state/etc) like how much funding the school gets and/or teacher salaries. Is it any wonder there was that scandal (Atlanta area?) a few years back where there was teachers and admin were changing scores en masse?

    • FormerPhysicist

      Even without changing scores, you end up as a teacher doing drill and kill for weeks. And you can’t unilaterally disengage. Clearly the BFHI is similar.

  • RudyTooty

    You’re right. Hospitals have incentivized exclusive breastfeeding rates – above health and well-being and personal preference of our patients. And that’s why we have this mess.

    I had a discussion with a colleague the other day where she said our breastfeeding rates were “worse” than she expected. And I thought to myself – assigning any value to the collective rate of breastfeeding at our hospital reveals the bias toward breastfeeding in itself. Why is one rate “worse” than another? What if 100% of women wanted to formula feed? If we honor and respect the choice our patients on how to feed their babies, why should any rate of exclusive breastfeeding be worse or better than another?

    • MaineJen

      What if the metric was: women who indicate they WANT to breastfeed are able to do so??

      • FormerPhysicist

        I suspect that would be better, but still problematic.

        If I make the analogy to surgery – I had a double mastectomy. Before surgery, I discussed with my surgeon what I hoped for. Her constant response was essentially “I’ll try, but we will have to see what we find during the procedure”. In the end, I was able to keep my nipples, but had to have expanders if I didn’t want to end up with very small breasts. The expanders were so painful over the next year that I chose to lose a cup size instead of stretching my skin to go back to my former breast size. A metric that asked if women went to their preferred breast size after mastectomy would unfairly penalize the surgeon, or lead her to pressure me to stay the course and discount my autonomy. *I* changed my mind based on new information, and facts about what my body could do easily or not.

        If about 15% of women have low breast milk supply, then we need to accept that many of those women will change their mind about breastfeeding. They wanted to, but not at the cost of triple pumping, for example. Somehow, the metric should account for that.

        • FormerPhysicist

          And a further thought on metrics and patient satisfaction surveys:

          If you ask me if I am happy with the size, shape, look and feel of my breasts: No, I am not. But I am 100% happy with my surgeon. She has assured me she could make corrections, but I am not willing to undergo the surgery – neither the disruption to my life, nor the pain. My dissatisfaction – that’s life. What do I want done about it? Keep researching new methods of treatment and reconstruction. Maybe we’ll get better.

          It’s HARD to get a survey or a metric to tease out that information properly. And hard to avoid unintended consequences when you measure and incentivize a particular part of the whole.

          • KeeperOfTheBooks

            That is a really interesting perspective; thank you!

      • RudyTooty

        Or we could toss out these metrics altogether. I dunno. Quality improvement is a good thing… I think.

        But back to your point, if 0% of women wanted to breastfeed, I would call any breastfeeding rate greater than 0% a failure.

        It’s the bias toward breastfeeding as inherently good or desirable – not to the person who would be breastfeeding, but to the system – that is the problem.

        Also, if a woman wants to breastfeed, and then changes her mind – FOR ANY REASON AT ALL – that should be respected, and not considered a ‘failure.’

        It’s silly to even hold women to what they wanted, or said they wanted, in the past. Women have the right and authority to change their minds.

      • Merrie

        Well, then women who want to breastfeed who end up not able to do so for some reason, or change their mind, are showing up as “failures”.

        I could see something like assessing moms at discharge to see if they’re satisfied with the help they got with infant feeding. This would measure how well providers are supporting their patients at achieving their own goals and has room for both a mom who wanted to FF and was given the supplies she needed, and a mom who wanted to BF and got help from the nurses and LCs. Though it would lead to some people who are cranky because they wanted a particular outcome and it didn’t pan out, getting mad because they’re getting help of a variety they didn’t want (baby is starving and nurse encouraged them to give formula, say).

  • Cartman36

    I found that at both BFHI I delivered at, once I got them to provide me the formula I wanted in order to supplement, they no longer gave a sh1t about my breastfeeding. They only care if you are EBF. With the first one, I had to argue and fight to get that first bottle. At the second one, I made my choice to supplement known before I was even taken in for the C-Section so they went ahead and (after trying to dissuade me initially) stocked my bassinet drawers with formula. I also had to use the formula feeding chart to record both breast and bottle feeds because they didn’t have one for supplementing.

    • Jessica

      I had the same experience. Once I was non-exclusive with my son (I had supplemented because he was hungry and I was exhausted, and he was borderline high birth weight so they were watching his blood sugar), I stopped getting any lactation consultants even though I was still primarily breastfeeding. To be fair, I probably could have got them if I wanted. But they stopped coming by every shift.

    • AirPlant

      SO I am stuck delivering in a BFHI hospital and what I am hearing is that I can nip the harassment in the bud by just getting a rubber nipple in her mouth ASAP.

      I am writing this down as a #lifehack.

      • Cartman36

        It made the experience much better for me to be really upfront about supplementing from the beginning. When asked why I wanted the formula in our bassinet drawer right then instead of waiting to see if it was needed, I explained that I would not repeat the experience I had with baby #2 were I finally had to yell at the night nurse to bring me formula because he was clearly hunger after an hour of BF and she had the balls to suggest I put him back on the breast.

      • alongpursuit

        Ohhh! This is good advice! I will deliver this summer in a BFHI hospital and I’m looking for ways to keep the breastfeeding zealots away. With my first baby I had a horrible experience with the lactation consultants and it really destroyed my confidence as a new mom. Maybe I could wear a Similac t-shirt while I recover? I will embrace the combo feeding with this baby and save myself the soul-destroying hours at the breast pump trying to increase my tiny supply.

        • Sue

          Could they supply some sort of a sign for your door? “Lactivists keep out”, for example?

          • Allie

            How about a large Rottweiler “support dog” by the door trained to growl on command : )

      • KeeperOfTheBooks

        Ayup.
        I delivered three times at the same BFHI hospital. The only time I didn’t get hell from people about breastfeeding was with the one kid who I walked in and said “I’m formula feeding, period” right from the start. (And to her credit, the LC who popped into recovery, upon hearing my “no thanks, I’m formula feeding” smiled, said “No problem! If you happen to change your mind and would like any help, here’s my card! Congratulations on the cute baby!” before trotting off.)

      • seenthelight

        Bring ready to feed bottles with you and put partner (assuming you have one) on delivery-suite duty – basically have the bottle ready to go the moment baby wants food, because you can’t rely on the hospital to do it for you.

        My second baby was headbutting my chest within a half hour of birth and we weren’t prepared. Poor girl hadto wait until we were transferred to our room. I still feel terrible about that and it’s been four years. I did my part to bring down their EBF numbers, though! Yay! And in the greatest irony, that baby EBF until she was 15 months. As soon as she got a taste of breast milk when mine came in, formula was not going down her throat again. I hated it and, if I could go back in time, I would have never even offered the breast. She grew so attached to ME that she would scream incessantly when I left her anywhere, so forget babysitters. She still theatrically cries when i drop her off at preschool. Who knows if formula would have changed that -probably only if I made other people feed her as often as possible – but it’d be worth a shot if I had a time machine.

    • FormerPhysicist

      Sounds so obvious. If they are only counting exclusive BF, then one bottle, and they don’t care any more. You’re already in the “negative” count. Stupid in many many ways.

    • Kelly

      My last delivery even though I was formula feeding going in, it took almost an hour to get a bottle since they set up the first hour after delivery for skin to skin and family time. I was incredibly annoyed and thankfully the delivery nurse kept pestering the other nurse to bring one in because my baby was hungry. They refused to weigh, give shots, or eye goop until we had our hour though. They didn’t even ask me what I wanted and I got a stupid lecture for not doing skin to skin. After that first hour, everything went much better but I wish instead of catering to breastfeeding they had asked me before I delivered, just like they did the last two times, my preferences.