Fellow physicians, why are we letting the Baby Friendly Hospital Initiative harm our patients?

danger tapes, danger sign

No one truly knows how hard a doctor works on behalf of patients than another doctor.

I understand how obstetricians struggle to make the right decision on when and how to deliver a baby to maximize the health of both infant and mother. I know what it’s like to confront at a worrisome fetal monitor tracing, unable to determine whether it represents real fetal distress but having to act anyway. I’ve lived the gut churning terror of a shoulder dystocia. I’ve been woken out of a deep sleep, snapped to awareness and raced to save a woman who showed up on the hospital doorstep hemorrhaging from a massive abruption, desperately hoping I’m not too late to save the life of her baby, too.

We give our all in service to our patients. Then we hand them over to the lactation lobby that harms both babies and mothers.

We and our pediatric/neonatology colleagues give our all in service to our patients. Then, too often, we hand them over to the lactation lobby that harms both babies and mothers. I’m referring, of course, to the so-called Baby Friendly Hospital Initiative designed to promote breastfeeding.

But wait, I hear you say. Doesn’t the conventional wisdom tell us breast best?

If you are as old as I am, you probably remember when the conventional wisdom was that routine episiotomies were best, that routine hormone replacement therapy for menopause was best, that routinely putting babies to sleep on their stomachs was best.

All too often the conventional wisdom is wrong and this is another case. Routinely pressuring all women to breastfeeding exclusively is wrong. Routinely withholding pacifiers and infant formula is wrong. Closing well baby nurseries and routinely forcing 24/7 rooming in is wrong.

How wrong?

This wrong:

Taken together, these papers demonstrate that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS, extended skin to skin contact lead to babies falling from their mothers’ hospital beds or suffocating while in them, and the latest results from the PROBIT studies show no impact on IQ at age 16. In addition, we know that the leading cause of jaundice induced brain damage (kernicterus) is breastfeeding.

The BFHI is a creation of La Leche League; it’s a full employment plan for its leaders allowing them to monetize the information they previously gave away for free.

So wrong that exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmission, accounting for literally tens of thousands of hospital readmissions for dehydration, jaundice and failure to thrive each year.

And those benefits we were taught about in medical school? Nearly all have been debunked.

It’s been 5 years since the publication, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey that found the purported benefits of breastfeeding nearly all disappeared with corrected for confounding variables like socio-economic status and ethnicity.

A recent paper, Is the “breast is best” mantra an oversimplification?, is a comprehensive summary of breastfeeding research and concludes that the benefits have been overstated and the risks ignored.

The evidence for infant breastfeeding status and its association with health outcomes faces significant limitations; the great majority of those limitations tend to overestimate the benefits of breastfeeding. Nearly all evidence is based on observational studies, in which causality cannot be determined and self-selection bias, recall bias, and residual confounding limit the value or strength of the findings.

And there is growing evidence that the BFHI is harmful to mothers as well as babies:

The literature that does investigate harm consistently finds that women who have difficulty breastfeeding or choose formula feeding report feelings of inadequacy, guilt, loss of agency, anxiety, and physical pain during breastfeeding that interferes with 1) their ability to bond or otherwise care for their infant and 2) competing work obligations…

Why have we been promoting breastfeeding so aggressively?

The BFHI is a creation of La Leche League and is essentially a full employment plan for its leaders, allowing them to monetize the information they previously gave away for free.

…[T]he BFHI was crafted in close conversation with individuals from La Leche League’s inner circle. First, early work by UNICEF and the WHO to develop the BFHI includes language which reproduces key components of La Leche League’s commitments…

[I]t’s also possible to trace the influence of individual policymakers from La Leche League in the 1970s to UNICEF in the 1980’s…In fact, the extensive connections between La Leche’s leadership and the WHO and UNICEF are well documented in the archival record of the League. These collections detail the involvement of the organization’s leadership, including its president Marian Thompson …

At the same time, LLL was engaged in an effort to monetize breastfeeding support, creating the lactation consultant credential.

The International Board of Lactation Consultant Examiners® (IBLCE®) was founded in March 1985 using a $40,000 loan from La Leche League International as start-up funding…

These factors of consumer demand, scientific evidence and practical clinical skills converged to create an ideal climate for the new profession…

Not exactly. The heart of the BFHI program — the Ten Steps to Successful Breastfeeding — were operationalized BEFORE there was any scientific evidence to support them.

It was not until nearly a decade after the birth of the program, in 1998, that the WHO published a review of scientific evidence in support of the Ten Steps. Their review of the scientific literature at that point served not to inform or influence the design of the BFHI but instead to defend the initiative as it had been initially drafted.

Think about that: a program designed by LLL to be staffed by its members was implemented without ANY scientific evidence to support it. It’s no wonder then that the BFHI has ended up harming our patients.

Fellow physicians, we have the power to protect our patients from the BFHI and we should use that power. The BFHI is a private organization; they can be removed from hospitals altogether or they can be forced to amend their guidelines to put preventing harm to babies and mothers first.

You work so hard to ensure the health of every baby and every mother. Please don’t let the lactation lobby continue to harm them.

  • KeeperOfTheBooks

    It’s obnoxious. My awesome OB, now, alas, retired, used to be the local go-to doc if you wanted to have a natural birth, or VBAC, or even, should things look favorable, VBA2C. He was very supportive of breastfeeding without being pushy about it. And yet, despite all that, he told me he fought tooth and nail against his hospital getting BFHI status because he saw the rooming-in thing in particular as dangerous to both moms and babies. Unfortunately, he was outvoted. I’m all in favor of room-sharing if that’s what a mom wants and it’s safe for that particular mom/baby duo, but to insist on it No Matter What is a disaster waiting to happen, and one that has happened in an increasing number of cases. Argh!

    • The Bofa on the Sofa

      I’m trying to figure out how we went from “Women should be allowed to room in if they want” to “no nurseries allowed”?

      Ok, I understand exactly why hospital administration liked it, but why doctors and other healthcare providers?

      • KeeperOfTheBooks

        Best I can figure is that they’ve been hammered with “Breast Is Best” so much and so often that they think that the supposedly minute risk of exhausted moms rolling over on/dropping their babies is outweighed by higher breastfeeding number. I also suspect some bias not unlike those who are against, say, the measles vaccine without ever having seen a case of measles: they haven’t seen this issue in person, so it doesn’t exist.

  • Sue

    Just a thought – should that theoretical calculation of how many babies could be ‘saved’ by exclusive BF (I’ve forgotten the author’s name) be revised to include the lives lost?

    • rational thinker

      They are not interested in that number. They just pretend it does not exist.

      • NoLongerCrunching

        That is true. The lactivist mindset is that there are no risks to exclusive breastfeeding, only to inadequate support and follow up . I am not even being sarcastic, that is the mindset. The idea that there are risks to exclusive breastfeeding is preposterous.

  • AnnaD2013

    I really appreciate the citation of the scientific literature & research in this article!

    Anecdotally speaking, both my OB and my baby’s Pediatrician were very supportive of stopping BF’ing when it wasn’t working for me or my newborn. I was very upset over weaning to formula, but my baby’s pediatrician said that my daughter would have no problems growing and developing with formula as her nutrition. Hearing that from a professional helped me immensely!!!

  • mabelcruet

    This was a case we had in England a few months ago:

    https://www.theboltonnews.co.uk/news/16443589.newborn-baby-died-in-mums-royal-bolton-hospital-bed/

    A co-sleeping death of a newborn in hospital. The response from the hospital absolutely beggars belief-a baby is dead and the spokeswoman (Head of midwifery there) is boasting about the hospital being a “Level Three UNICEF baby friendly initiative accredited unit which is the highest standard for breastfeeding and is a prestigious award…”

    • rational thinker

      I just read the article this is a disgusting person (midwife) to try to lie her way out of responsibility for a death that mostly she caused. Maybe it is time for the government to get involved. Maybe if we can get one country to ban BFHI practices other countries would follow suit. I think that may be the only way to end this.

  • mabelcruet

    I think a big issue is a lack of understanding of how medical research progresses-there are people out there who seem to think that about-turns on medical advice means that doctors don’t know what they are talking about and the ‘fact’ that guidelines and recommendations are changed regularly is proof of this. One year we’re recommending episiotomy, the next we are saying they are useless and shouldn’t be done. So they extend this thinking to other areas and end up in a mind set of ‘you can’t trust doctors, you can’t trust their advice because they flip-flop on issues’. In the face of this uncertainty, its not surprising that mothers end up trusting the people who make rigid and inflexible announcements because they sound so confident and unambiguous-breast feeding is ALWAYS best, normal birth is ALWAYS better than medicalised birth, epidurals WILL cause chronic back pain. And the type of people who make this sort of statement (lactivists and that crowd) have little appreciation of risk, little practice with quantifying that risk and explaining it to patients, and no understanding of patient autonomy or consent. They tell mothers just enough to ensure that the mum makes the decision that they want her to make and pretend she was fully informed.

    Medical recommendations change in response to new evidence-its a strength, not a weakness, to be open to change.

    • AnnaPDE

      It would help the credibility of medical recommendations a lot though if their current iteration wasn’t announced with the certainty of an unquestionable law handed down directly from some deity. I get that policy makers want recommendations as idiot proof and simple as possible, but for the segment of the population that has a bit better memory than a goldfish and a modicum of critical thinking, this approach backfires both short and long term.

      • mabelcruet

        I get that, but the problem is that the message needs to be comprehensible by everyone and when you’re dealing with an entire population that can be difficult. Take the co-sleeping medical advice-if you issued advice that accurately reflected risk it would end up reading ‘co-sleeping is safer if you do this, this, and this, but only if you don’t do that, but if you do this, then you have to do that too’. It’s less confusing to just say ‘don’t co-sleep until your baby is 12 months old’, that way it can’t be misinterpreted. However, this can come across as rather paternalistic and patronising-just do what I say.

        It can be difficult finding a form of words that suits population-wide. We came across a similar issue when we redesigned our autopsy consent forms a few years ago. The parents have to fill in a consent form that covers all aspects of the autopsy-external and internal examination, genetic testing, photographs and X-rays, whether they consented to organ retention or not, whether they permitted the autopsy to be observed by trainees or not, whether they consent to tissue samples being used in medical research or not, multiple sections to do. It comes with a booklet of explanation, and they have to sign and say they have received sufficient information and have had their questions answered. This is all required by the human tissue act, so we have to do it. We had more complaints than I can count about the form-its too long, it’s too complex, it’s too upsetting to read about organs, it’s too intrusive to describe the process in that way, can’t we just get on with it and do what we need to do, they trust the pathologist to just do what the pathologist thinks is necessary etc. But this is what got us into trouble before-the consent forms before the organ retention issue were basic and just vaguely mentioned ‘I consent to the retention of tissue if necessary’. The intention was that if people wanted more information they could ask about it, as different people need different amounts of detail.

        I suppose it’s similar with public health statements like ‘don’t co-sleep’. A parent who wants to take it further could ask and say ‘how can risk be reduced in co-sleeping?’ and the more nuanced information given that way.

  • rational thinker

    Hypothetically speaking perhaps some organization can start a new initiative called the Family Friendly Hospital Initiative. If for example the BFHI pays a hospital say ten thousand to be implemented as hospital policy then maybe if a newly formed FFHI could give them 15 thousand and outbid the BFHI . Then maybe the nightmare called the BFHI would end because sadly a lot of things ARE about money not people.

    • Angharad

      BFHI doesn’t pay hospitals; hospitals have to pay ($9900-$12,600 up front, plus $1500 or $3000 every year afterwards) to become certified as a BFHI institute. Which makes it even more baffling that it is becoming such an entrenched part of our hospital system.
      Source: https://www.babyfriendlyusa.org/for-facilities/finances-and-fees/

      • CSN0116

        It’s a worthwhile investment. First, it allows them to market the status, as if it’s something good, to the unknown. Second, it gives them reason to understaff and close well nurseries, saving hundreds of thousands per year.

        • alongpursuit

          Especially with the misnomer of “baby friendly”. At a glance I thought it would maybe be a gentler experience for my baby — little did I know it would be awful for baby, husband and especially me.

      • rational thinker

        Sorry my mistake. I meant to word that differently, but anyway its not just being paid for with money anymore it is also paying with human lives and that is never ok. It does probably save a hospital money in the long run with under staffing and closing nurseries.

    • Daleth

      Dr. Tuteur, let this be your next calling, perhaps! We will all pitch in 🙂