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.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”[T]he 10 steps should not be treated as the equivalent of the Ten Commandments …”[/pullquote]

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.