(Nearly) everything wrong with the Baby Friendly Hospital Initative explained in one paper

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When you spell it out, it sounds appalling. The Baby Friendly Hospital Initiative, designed to promote breastfeeding, is very unfriendly to mothers, dangerous to babies, and ignores the scientific evidence. Why then has it become so popular?

A new philosophy paper, Understanding the Baby-Friendly Hospital Initiative: A Multi-disciplinary Analysis, attempts to answer this question.

The authors take great pains to soft pedal the ugly realities and — in an effort to protect themselves against the inevitable lactivist accusation that they must “hate” breastfeeding — repeatedly insist that they support breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Why has the BFHI — unfriendly to mothers, dangerous to babies, and contemptuous of scientific evidence — become so widespread and politically correct?[/pullquote]

Wading through the apologetic language makes it clear that the BFHI is unfriendly to mothers:

…[S]ome women claim that Baby-Friendly policies have contributed to negative postpartum experiences, arguing that Baby-Friendly hospitals are not “mom-friendly.” For example, some mothers report that they are being inappropriately pressured to breastfeed, or express frustration with hospitals who refuse to provide or support formula supplementation. In addition, mothers have argued that 24-7 rooming-in practices do not take seriously the needs of mothers to rest and recover …

[I]n a survey of postpartum patients in a Baby-Friendly Hospital, 28% responded “neutral or disagree” when asked if they could rest and recover in the hospital. Among mothers who had decided to formula feed, 26% reported feeling shamed for the decision to formula-feed and 37.5% did not feel adequately informed about formula-feeding.

Moreover, with its insistence that “breast is best” for every mother and baby, the BFHI fails to provide appropriate understanding and support for women at high risk of poor outcomes:

For example, staff at the Massachusetts General Hospital’s Center for Women’s Mental Health have described Baby-Friendly policies as being insensitive to the needs of patients who are at elevated risk for postpartum depression, as such mothers are particularly in need of time to rest and recover after delivery…

If that weren’t bad enough, the BFHI places babies at risk for deadly complications because it ignores scientific evidence:

…For instance, researchers have reported that there may be a link between skin-to-skin contact in the hours after birth, which is promoted by BFHI policies, and Sudden Unexpected Post-Natal Collapse (SUPC), a life-threatening condition for a newborn. Additionally, the emphasis on breastfeeding, together with rooming-in policies, may encourage unsafe co-sleeping practices by postpartum mothers, some of whom are recovering from major surgery. Finally, current Baby-Friendly policies ban pacifier use, even though pacifiers appear to lower the risk of Sudden Infant Death Syndrome.

How could a program that treats mothers badly and poses deadly risks to babies have become both popular and politically correct? It reflects our cultural construction of motherhood:

…[O]ur normative conceptions of motherhood dispose us to undervalue and overlook maternal interests when benefit to children is at stake, and thus we overlook the costs of BFHI practices to mothers, or treat these costs as obviously acceptable given the potential health benefits …

How could a program that places babies at risk of serious injuries and death have been allowed to continue?

Since the modern breastfeeding movement began in the 1950s, some advocates have embraced the argument that breastfeeding is natural, and that natural things are endowed with a kind of biological morality that makes them superior, better, and healthier by default… This view of breastfeeding as natural, and of “the natural” as superior, healthier, and less risky may help to explain how questions of safety for mothers and infants have been left unasked, and may have shaped the creation, implementation and support for the BFHI.

Rather than addressing the problems inherent in the BFHI, the process of implementation has amplified them:

…[U]nlike research science, which emphasizes well-designed studies and careful analysis, quality improvement emphasizes quick implementation of what is termed “best practices.” The motivation for this approach is based on two beliefs: first, that healthcare faces a quality crisis in which patients are routinely poorly served and, second, that scientific research proceeds too slowly to be of practical benefit. Thus, instead of waiting for research science to conclusively prove the benefit of an intervention, the emphasis in quality improvement is on learning from “success stories” at other facilities… This process typically unfolds over a period of months, and it is contrary to the norms of the field to wait for an extensive evidentiary base to be developed.

Institutionalization leads to “one size fits all” policies:

…[Q]uality improvement places great emphasis on the standardization of care pathways… [P]ressure towards standardization can lead providers to overlook subpopulations of mothers who are ill-served by the standard approach, such as those suffering from depression or anxiety.

…[W]hile some quality improvement initiatives are small and flexible, … others are embedded in multi-layered institutional structures… As quality improvement work becomes more institutionalized, with multiple layers between practitioners and administrators, it also becomes less flexible. In the case we have been discussing, first-line practitioners have identified a potential problem with the existing intervention—it may not be well-suited for mothers with depression—but they are effectively powerless to act on this knowledge. If they stop following the standard protocol for these mothers, they will damage their TJC accreditation scores, and possibly endanger the accreditation of the hospital as a whole…

The ultimate irony of the BFHI is that a program that was designed to facilitate choice for mothers has become a program that pressures mothers to make only ONE approved choice. A program designed to give women the option and support for breastfeeding has become a program to pressure women into breastfeeding. A program designed to give mothers the option of rooming in with babies has become a program that forces women to take full responsibility for the care of babies before they have recovered physically from birth.

The authors offer specific suggestions for improving the BFHI:

First, because an ethic of total motherhood encourages new mothers to downplay their own interests, the BFHI should counteract this tendency by including language which recognizes and values the interests of mothers…

Second, we have argued that institutional pressures tend towards one-size-fits-all policies which become institutionally rigidified. One way to counteract this would be to explicitly acknowledge, within the Ten Steps, that mothers have diverse needs and preferences…

Third, while we believe it is possible for breastfeeding promotion to be conducted in ways which respect the full diversity of maternal interests, we are pessimistic about breastfeeding promotion within medical contexts which are subject to compliance-oriented quality improvement…

This paper is timely, thoughtful, acknowledges the dismal realities of the BFHI and suggests correctives.

In my view, however, it ignores two critical factors. In an effort to ward off the inevitable accusation that they authors “hate” breastfeeding, they repeatedly affirm their support for breastfeeding without ever addressing the fact that most claims of benefits for term babies in industrialized societies have been debunked. The reality is that breastfeeding is not beneficial enough to warrant major efforts to increase breastfeeding rates.

The second omission is more problematic. Although the authors address the institutionalization of the BFHI, they fail to acknowledge the monetization of breastfeeding support and the resulting economic conflict of interest between lactation consultants’ desire to increase demand for their services and women’s desires to control their own bodies and make the feeding choices that are best for their specific circumstances.

Nonetheless, the authors have performed a valuable service is setting out the parameters of the debate. Why has the BFHI — unfriendly to mothers, dangerous to babies, and contemptuous of scientific evidence — become so widespread and politically correct? Because of outmoded views about women, erroneous views about natural processes, and the imperatives of large institutions, not because it’s best for babies … since often it isn’t.

  • GeorgiaPeach23

    Another check in on my breastfeeding journey. Got it figured out right before going back to work. I produce a lot in the morning and my baby has the biggest appetite at night, so the pump is pretty essential. I have no idea what we’d be doing without the pump even if I wasn’t working. The baby has stopped accepting formula even when served in the same bottle.

  • Sara

    I found my baby friendly hospital experience supportive and mom-friendly. in-room babycare was convenient. The nurses were very involved and would come in to check on my baby while I slept and recovered. My baby was only brought to my breast to nurse. I don’t recall anyone talking about nursing to sooth as the other commenters bring up. I felt very taken care of and educated. I didn’t feel pressure to breastfeed. I can totally understand a policy to ask first about offering bottle or formula to the baby. They are trying to set up the family for breast feeding success IF it’s available and desired by mom. MD’s all recommend breastfeeding if you can so of course this be the default within the hospital.

    Ever hospital is different, but in my experience the “baby friendly” hospital staff are doing their best to educate, and some moms might need that education. I don’t think that “baby friendly” means “baby friendly at the expense of mom.” In my experience, it was the right environment for a healthy start.

    • demodocus

      I’m glad your’s was a good experience. Mine wasn’t too bad either, though that LC was bossy and arrogant af. Sigh. I hope a nurse stayed in the room when they had me bf’ing my baby, with a catheter and a magnesium drip. I do _not_ remember that first night because I was so out of it.

      Like anything else, there’s a spectrum, and our good fortune doesn’t discount others’ misfortune any more than the reverse

    • KeeperOfTheBooks

      And if that’s what you want, great! I’m genuinely glad it was a good experience for you. 🙂
      It…wasn’t…for me. I’ve had three babies in baby-friendly hospitals now. With the first, the LCs were definitely the worst: among other things, they told me to cosleep with my baby propped on pillows under a blanket against my side so baby could nurse while I slept. I should add that I was fairly obese at the time. Cosleeping isn’t safe, but that isn’t safe even by cosleeping standards! There was also an incident where she turned blue on the breast because I was smothering her due to bad positioning. No one said anything about safe practices.
      Baby number 2 I said from the start that I wanted to FF, and got no grief about it, but I also had no help from the staff in terms of sleeping or baby care. At one point, I was literally hallucinating from a medication combo, but was still expected to be the sole caregiver for a newborn.
      With baby number 3, I made the asinine mistake of trying to breastfeed again and was punished appropriately by getting a host of lactation consultants and nurses telling me what I already knew and, in retrospect, probably lying to me about my baby’s weight. (I seriously doubt that the massive weight loss he had at the appointment a couple days after I was discharged ONLY happened in those two days.) They also withheld my prescribed pain medication despite my repeated comments about “look, I’ve had two other C-sections and the pain has NEVER been like this, is there something wrong?”…and only told me around day 3 that “well, we’ve been cutting your medication to half the prescribed dose, but are you sure you need it? It might make you tired.”
      When I complained about the lack of help and unreasonable expectations (“you need to take a shower, but you can’t leave baby alone, but we won’t take baby either,”), I was told “well, you’ll be doing it all yourself at home, so you might as well get used to it now.”
      No. At home, my husband or mother-in-law would happily watch the baby while I showered or took a nap. I would be more than a few hours out from major surgery. I could take pain medication for the few days I need it without someone other than me and my doctor deciding that abdominal surgery doesn’t need more than Tylenol. Etc.

      • FormerPhysicist

        I HATE that comment “you’ll be doing it all yourself soon”. I got it too, and it’s complete BS.

        1) I won’t be. I’ll have help. Some women will be doing it all themselves and I feel for them, but many won’t.

        2) I’m in the hospital now because I’m recovering, sick or need help. If I was ready to do it all myself, and perfectly healthy, I’d GD check myself out of the hospital! If I get to the standard number of days after birth and I’m NOT healthy, you’re going to keep me here.

        3) Again, no one recommends solo infant care after any other event/procedure. Gallbadder attack? Hey, here’s a helpless infant to take care of by yourself…

        4) Oh, for the “natural” argument, homo sapiens have social structures. For most of history, women haven’t done it all themselves with no help. Our brains and communities are what allows us to thrive and be at the top of the food chain.

        • KeeperOfTheBooks

          Right. This. All of it.
          I mean, in a pinch, I can think of a few friends who I could call if I got to the point that I was at at the hospital and sob out something about how I HAVE to take a shower, take pain medication, and sleep for 2-3 hours straight, and they’d drop everything to come and make it happen somehow, just like I have told them to bring baby and big kids here, I’ll set mom up with a bed far away from the noise, go get a shower and a decent nap and I’ll cook you a meal when you wake up. Because that’s what a decent person does. It’s like they WANT us all to revert to the lowest possible denominator of human behavior and not help each other, and it’s appalling.

      • Kelly

        One of the reasons I pushed to get out of the hospital as soon as possible was that I could have my mom hold my baby while I took a nap in my own bed with a fan on so I could block out all the noise. For some reason, the hospital was so dang loud this time around and my husband and I got absolutely no sleep.

    • rational thinker

      It may be have been good for you and other mothers who WANT to breastfeed but many other mothers have been abused more ways than one by this system. Taking away nurseries is unethical. Many mothers who have had c sections and are on heavy pain killers should not be made to take care of a newborn as this can and has resulted in the deaths and injuries of newborns. When I had my first I had to care for my son by myself after having forth degree tears, but they did not seem to give a shit except for maybe one nurse (the one who had to mop up all the blood on the floor when I had to get up a few hours after birth still attached to an iv to take care of my son).

      “MD’s all recommend breastfeeding if you can so of course this be the default within the hospital.” — This is just not true. Most good doctors will recommend what is going to be the most medically and mentally beneficial for mom and baby and this is NOT always breastfeeding.

    • Adrienne

      I agree that there should be a policy about asking before offering a bottle or a pacifier. I don’t agree with what I had to do–which was sign a consent that doing so could have “serious negative consequences.” I’m also ok with nursing being the default in a hospital. What I disagree with is the “all-or-nothing” mentality that seems to accompany the decision/desire to breastfeed. Sometimes, slow and steady wins the race!

    • KQ Not Signed In

      Goody for you.

      My experience was that no one would help me, I was shamed for begging someone to take the baby so I could have a couple of hours of sleep, they several times propped the baby between my drugged and semiconscious self and the bed rail with a pillow, and by the time we left the hospital I was straight up hallucinating from sleep deprivation. I did EBF without issue, but the part where they shoved the baby on my boob when I was delirious from exhaustion and left us there, against a pillow, in a high up hospital bed, in an incredibly dangerous position… that part still infuriates me 8+ years later. Just give him a bottle and let me sleep long enough to be *safe* holding him!

      • PeggySue

        What a nightmare. I am so sorry this happened to you.

  • J. Raven Star

    You know – I hated breastfeeding. It was painful, difficult, messy, tied me to home and baby, resulted in leaky breasts and public embarrassment, painful breast swelling, and lurid comments from men who fetishized the whole thing. I felt guilt, but also secret pleasure, when I finally switched my son to formula.
    Hating breastfeeding should be the only reason any woman has to give for quitting. How good can it be for baby or mother if she is hating and resenting every moment of it? How much “bonding” is really happening?

    • Allie

      Slightly disagree – women shouldn’t have to give ANY reason for stopping breastfeeding or not starting in the first place.

    • mayonnaisejane

      The bonding thing always gets me. Babies bond. It’s their nature. It’s basic mammalian instinct. They are born primed and ready to bond. If you were an infant’s caretaker from birth, there’s a nearly 0 possibility of that kid not bonding to you, even if you’re the worst fuckup of a parent ever. Kids routinely bond to incredibly abusive parents after all. It’s survival. A baby depends on adults for all needs, so their priority #1 is forming a bond with one (or more) of those adults to ensure said adult will care for it. What doesn’t always happen is the parent(s) reciprocating that bond immediately. Sometimes that takes time to work up the bond… but it’s not the baby who isn’t bonding yet, it’s the parents. (No judgement on the parents, just saying that though it may feel like the baby isn’t bonding with someone, really the baby is bonding and the adult just can’t feel it yet.)

  • Emilie Bishop

    It has taken me four years to summarize my experience with a BFHI this way: “They could have killed my son because we had a host of breastfeeding complications and they lied to us about every single one.” I tell every pregnant woman I know, and the ones who aren’t pregnant yet are told to choose another hospital (I live in a large metro area with many choices, most of which aren’t BF). I really hate thinking so badly of the providers in my hospital, but the fact is that it was far more important that we breastfeed than that we have a healthy start to life and motherhood. Disgusting, but their actions leave little to no doubt.

  • Adrienne

    I’m sure it will come to naught, but I gave my hospital a scathing review after the birth of my 4th child for it’s “Baby Friendly” hospital. I had a super quick labor in the morning (9:30-11 AM) but was still exhausted after the first night alone in the hospital caring for the baby (who didn’t sleep) by myself. My husband was home with the other children. At home, a second adult is there to help, and I put the baby in another room so I can get some sleep without hearing all the baby noises. They made me sign a consent to give the baby a pacifier (that it could have “serious negative consequences”) as well as for formula even though I had successfully nursed three other children for more than a year. My babies have had tongue-tie (I know that that is controversial on this site) and I am very careful about nursing until an ENT looks at my babies because my first tore me to shreds in the first few weeks (and almost ended the whole nursing thing all together). My babies are allowed to nurse to eat, but not to soothe. And I explained this to the lactation consultant who nodded knowingly and sympathetically, and then explained that my babies should be allowed to nurse as often as they want for as long as they want. Grrr. It was only because this was my 4th child that I was unable to withstand the pressure of it all, sign the consent, roll my eyes at the lactation consultant, supplement with formula and give a pacifier…and now, with a nearly six month old I am, in fact, exclusively nursing. No thanks to them.

    • alongpursuit

      It’s really interesting to see your perspective on the BFHI as a mom of 4 kids. I had a similar hospital experience after labor and delivery, but it was my first baby so I didn’t have the wisdom of knowing what would work best for us.

      My first had a very pronounced lip tie and I was also injured by trying to nurse her to feed her and to soothe her (as I was told to do). In hindsight, I don’t think she stimulated my breasts enough to bring on a decent supply because of this lip tie. By day 4 I was in severe pain and not producing anywhere near enough milk. She also lost too much weight and I was told to supplement. I also hadn’t slept because even while she was sleeping her little newborn noises kept me awake. I know for next time that I’m too light of a sleeper to be rooming-in with a baby.

      Next time, I plan on using early formula supplementation since it’s supported by evidence (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666109/). And I like your idea of nursing to eat but not to soothe — especially if I’m getting nipple damage. These 2 things could have helped our chances at breastfeeding.

      • Adrienne

        I wish new moms knew that neither bottle nor a pacifier will ruin their chances of breastfeeding FOREVER. It usually takes me weeks to work up to exclusively breast feeding—in the interim I’m pumping and bottling. Feeding your baby is so primal and there is so much tension around it—I was an absolute wreck after my first. I think a different kind of support would be so helpful to new moms. Second time around—you got this. And if you don’t—well, by the time they’re one, no one asks, cares or can tell if they got breast milk or formula.

        • alongpursuit

          Wow this is so enlightening! Thank you! No one ever told me that it could take weeks to work up to EBF. I like this idea of pacing myself and ramping up. I completely burnt myself out with the breastfeeding the last time and by the time my baby was in dire need of supplementation I felt like I had completely failed AND my nipples were basically falling off. I really wish I had had more realistic help with the breastfeeding — maybe I would have succeeded the first time.

          • Adrienne

            I think I’m an outlier. But it took me probably 5 weeks with my first. With my others it has gone faster because I am more careful to not allow an injury, but still probably 2-3 weeks. Initially I can only stand it twice a day, no more than ten minutes a side (and man am I staring at the clock!). But I keep my supply up through pumping, and have always made it, and have fat roly-poly babies. Take that, Friendly Baby Initiative!

          • mabelcruet

            Adrienne and Alongpursuit-this might come off as patronising, I hope it doesn’t, because it absolutely isn’t meant to be.

            This is what I like about this site. Two people, total strangers, having a friendly conversation, sharing hints and tips and suggestions, with no opprobrium, no sneaky back handed snide comments about ‘what a shame you don’t want your baby to soothe,’ just two mothers sharing experiences in a positive and supportive way to enable them to look after their babies in a way that they feel is best for them and their family. No value judgements about the way that works for them as individuals, no pressure to do it ‘the right way’, because it’s obvious you both know that’s what right for you may not be right for someone else-and you accept that, and aren’t trying to force your view as being the only correct view. Two mothers helping each other and building each other up! Why can’t all breast feeding conversations be like this??!!

          • KeeperOfTheBooks

            Agreed 110%!

          • fiftyfifty1

            This idea that the mother should be a 24/7 human pacifier has been terrible for breastfeeding. Many (most?) babies are uncoordinated with their breastfeeding in their first 2-3 weeks. They can shred nipples even without other challenges such as tongue tie. Lactivists always bemoan how today’s mothers have lost touch with the ancient breastfeeding wisdom of their foremothers because their own mothers didn’t breastfeed blah blah blah. But my own mother DID breastfeed as did her mother and grandmother. And all of THEM gave the advice to strictly limit time on the breast in the first few weeks to avoid nipple damage.

          • AND, what is rarely mentioned, if the breast is being used as a pacifier, the baby is learning how to overeat, because , along with the nipple there’s a slow dribble of milk, as it’s constantly produced.

          • GeorgiaPeach23

            Or undereat since the meal never has to end. My son is like that. I play certain songs to let him know he needs to finish, and he often nurses furiously when he realizes the tap is closing. A lot of times I put him down and THEN he realizes I’m serious about not nursing for the next hour, at which point he gets down to business.

            Momma has stuff to do other than have my nipples worn down, you know.

          • GeorgiaPeach23

            My friend had her baby 3 months after I did. I was in the hospital with her when the LC came around, and afterwards I told her all the things the LC had lied about or badly minimized. Her baby, like mine, has no idea how to latch. Mine learned over the first month, hers will do the same. I wish someone had told me that was normal — I didn’t get it til my friend experienced the exact same thing with a totally different baby/pregnancy. The LCs I saw blamed it on my baby being breech, but hers wasn’t. Or on him being small, but hers is a chunker. I want to help her avoid the agony and depression I experienced that first month.

            I think newborns are just fucking dumb and would die in the wilderness if their mothers didn’t agonize over getting food into their uncoordinated mouths. Formula is a miracle, so are bottles and artificial nipples.

          • KeeperOfTheBooks

            I don’t know if you’re an outlier, but you aren’t alone, either. My BFF always ends up breastfeeding, despite the fact that it takes her a week or so to get her supply in. So, she nurses some, pumps a bit, and tops off with formula until she has more milk and, most importantly, baby is full and happy.

          • Two platitudes: 1) Do whatever works for you and the baby, and 2) have the third baby first.

            Everything else, as they say, is commentary.

          • Allie

            Early supplementation is a lifesaver. I cannot understand why all the misinformation that it will ruin supply and derail nursing. Bull! It helps you maintain your sanity and feed your child while the two of you figure things out.

      • rational thinker

        I have noticed a reoccurring theme around infant feeding over the years:
        When exclusively breastfeeding= “Latch baby on your breast whenever he cries”
        When exclusively formula feeding= “Dont put a bottle in babys mouth whenever he cries”