New paper confirms Baby Friendly Hospital Initiative does NOT increase breastfeeding rates

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A new paper confirms what we have known for several years: the Baby Friendly Hospital Initiative is a failure on its own terms.

I’m not talking about the fact that it harms babies with its dubious “achievement” of making exclusive breastfeeding the leading risk factor for newborn re-hospitalization leading to tens of thousands of re-hospitalizations per year at a cost of hundreds of millions of dollars.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Instead of putting lactation professionals in charge of doctors and nurses; put doctors and nurses in charge of lactation professionals.[/pullquote]

I’m not talking about the fact that its insistence on forcing 24 hour mother-infant rooming in has led to a small epidemic of newborns suffocating in their mother’s hospital beds or sustaining skull fractures from falling out of them.

And I’m not talking about the soul searing guilt that as many as 15% of mothers experience when they are biologically incapable of producing enough breastmilk to fully nourish an infant, especially in the early days after birth.

No, I’m talking about the fact that the Baby Friendly Hospital Initiative (BFHI) appears to have NO IMPACT on breastfeeding rates after hospital discharge.

A new paper, Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public Policy Implications, looked at breastfeeding data for all the nearly 4 million infants born in the US in 2015.

Breastfeeding outcome data from the 2018 Centers for Disease Control (CDC) Breastfeeding Report Card were used as a basis for determining outcomes from the corresponding 2015 birth cohort. Linear regression models were used to determine the strength of association of breastfeeding initiation and Baby-Friendly hospital penetrance and attainment of postdischarge breastfeeding rates. All hospital births from all 50 states, 3 territories, and the District of Columbia were included in the study.

They failed to find ANY ASSOCIATION (let alone causation) between the BFHI program and breastfeeding continuation rates.

Baby-Friendly designation did not demonstrate a significant association with any postdischarge breastfeeding outcome. There was no association between Baby-Friendly designation and breastfeeding initiation rates.

The results are starkly presented in two sets of graphs.

Any Breastfeeding at 6 and 12 months:

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Exclusive Breastfeeding at 3 and 6 months:

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The left side of each set shows a strong correlation — not surprisingly — between breastfeeding initiation rates and breastfeeding continuation rates. As breastfeeding initiation rates rise, breastfeeding rates at 6 and 12 months and exclusive breastfeeding rates at 3 and 6 months rise. The correlation is not surprising since only those women who start breastfeeding can continue breastfeeding.

The right side of each set shows NO correlation between births at BFHI facilities and breastfeeding continuation rates. Those who gave birth at BFHI facilities are NOT more likely to breastfeed at 6 and 12 months (or exclusively breastfeed at 3 and 6 months) than those who gave birth at non-BFHI facilities. The increasing adoption of BFHI certification has had NO IMPACT on breastfeeding rates.

My take away:

Instead of putting lactation professionals in charge of doctors and nurses in an effort to increase breastfeeding rates, we should be putting doctors and nurses in charge of lactation professionals.

The findings of this paper are neither new nor unexpected.

By the end of 2016, it had become clear that the BFHI failed to increase breastfeeding rates. The paper Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms noted:

…[O]nly individual-level interventions demonstrated effectiveness at improving breastfeeding, whereas system-level interventions, including the World Health Organization’s Baby-Friendly Hospital Initiative (BFHI), did not.

By November 2018, enough data had accumulated for the editor of the premier breastfeeding journal to call for a review of the Ten Steps on which the BFHI is based. He noted that A Critical Review of the Baby-Friendly Hospital Initiative Is in the Works.

The author’s use of scare quotes is 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 there was no evidence that it was having any impact on breastfeeding rates. He concludes:

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.

The Baby Friendly Hospital Initiative chooses to incentivize hospitals, nurses and lactation consultants on certification rates and exclusive breastfeeding rates at discharge. There was NEVER any data that showed that either was correlated with breastfeeding continuation rates. Now there’s increasing evidence that they are definitively NOT correlated with breastfeeding continuation rates.

The BFHI is actually HARMING babies and mothers.

As the authors of the new paper note:

…concerns about associated neonatal sentinel events including sudden unexpected postnatal collapse (SUPC), newborn falls, and newborn dehydration and jaundice, which are recognized by the American Academy of Pediatrics, the WHO, The Joint Commission, and the CDC.

In addition, there has been increasing recognition of adverse perceptions of Baby-Friendly designation based on reports of the experiences of some mothers in Baby-Friendly designated hospitals. This is reflected in the new WHO Baby-Friendly Guideline statement on the need to respect maternal autonomy and avoid judgmental attitudes which could infringe on the mother’s dignity. The Breastfeeding Report Card outcomes also support the results of the recent US Preventive Services Task Force report, which demonstrated that Baby-Friendly designation was not a consistently effective intervention and that individual approaches were more successful.

The authors conclude:

Baby-Friendly designation penetrance did not demonstrate any positive postdischarge breastfeeding association.

In other words, putting a private organization of breastfeeding professionals in charge of breastfeeding in hospitals has been a terrible mistake and a failure on its own terms. If we want to increase breastfeeding rates and reduce breastfeeding complications, we should put hospitals, doctors and nurses in charge of lactation professionals.

The BFHI has become little more than a full employment program of, by and for lactation professionals. No doubt they are already penning their Letters to the Editor to defend the increasingly indefensible Baby Friendly Hospital Initiative. Let the excuses begin!

  • Sarah

    This does not come as a great shock.

  • Mel

    Back when I was in high school, an aunt of mine who is a long-time registered nurse was expounding on the dangers of spreading nursing duties to people with less training. She had listed off three tasks – and I can’t remember the first two – but it was essentially “sounds medical, sounds medical and washing babies!”

    Her sibs pretty much worked as non-medical human services folk like teachers or social workers so their response was “Well, I mean, washing babies sounds like a task that would be safe for anyone. ”

    She replied “Not if they miss the early signs of a critical heart defect like fingers or toes that don’t pink up correctly.”

    That caused everyone to think for a few minutes.

    Fast forward 10 years or so. The newborn granddaughter of my supervising teacher was diagnosed with a constriction point in her aorta after a nurse noticed that her fingers and toes were a bit blue. The kicker: her parents both had medical training and were practicing medicine – but not neonatal medicine…and they had just given birth.

    I have a hunch that sudden unexpected postnatal collapse (SUPC) may well better be described as “Not Enough Trained Eyes on Newborn” Syndrome – because I suspect the costs of BFHI certification are much less than running a well-baby nursery.

    Well, until the lawsuits start, anyways.

    • mabelcruet

      Absolutely-what trips people up are Donald Rumsfeld’s ‘unknown unknowns’. An experienced nurse will have seen so many babies that any showing signs slightly out of the ordinary will be immediately obvious-this is the origin of the ‘medical sixth sense’. Its not intuition or good luck, its years of training and experience that means your brain is busily assessing and computing without you really being conscious of it.

  • Emilie Bishop

    It pisses me off to no end that my son and I are considered “successful” by their metric because we left the hospital exclusively breastfeeding. We were rushed out 25 hours after delivery, multiple LC’s noting his latch score going down instead of up and my breasts having visible risk factors for low supply, but they got to check their almighty EBF box and then not report on his dehydration and readmission two days later. I hope this paper is a nail in the coffin of this shitshow because it needs to be burned to the ground.

    • Christine O’Hare

      Amen. And I would be considered a dismal failure since we supplemented formula while in the hospital, even though from the day we went home through 5 months we EBF.

      • Emilie Bishop

        Right? Seriously messed up. Good for you for supplementing when you needed or wanted to.

    • PeggySue

      Emilie Bishop, this is awful. I’m so sorry you and your son went through that.

      • Emilie Bishop

        Thanks. My son is almost five, yet these policies don’t change.

  • rational thinker

    “The BFHI has become little more than a full employment program of, by and for lactation professionals.”

    This is a very accurate statement of this industry, you should make a meme out of it Dr. Amy.

  • fiftyfifty1

    “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.”

    No, not even that. The goal of any initiative should be *actual healthy people.*

    • Emilie Bishop

      That caught my eye too. “Healthy” and “breastfeeding” don’t have to go together.

  • KQ Not Signed In

    “This is reflected in the new WHO Baby-Friendly Guideline statement on the need to respect maternal autonomy and avoid judgmental attitudes which could infringe on the mother’s dignity.”

    The very fact that the WHO needed to add this guideline says volumes.

    • Sarah

      It does, though I will admit I’m surprised. This being the same WHO that came up with the 15% section rate shite and made as little fuss as they could about dropping it. Perhaps the pendulum is swinging the other way.

    • Anna

      The whole thing is judgemental though and the evidence is overwhelming. You can’t just hold up a sign thats says “you’re a shit Mom!” and then stand under it trying to be a bit less judgemental.

  • Cartman36

    I’m so glad to see that the tide if finally turning on BFHI. It just stinks that so many families (I gave birth at two BFHs) had to suffer.

    I hope it stings for the hospitals that paid $12K + to get BFHI certification to see this data come out.

    I also noticed the hospital I had #3 at is no longer advertising their BFHI status on the billboard out front. I hope that it is because they are getting complaints.