January 13, 2020

Could the Baby-Friendly Hospital Initiative be hurting mothers—and babies too?

Daily Briefing

    In 1991, the World Health Organization (WHO) and UNICEF developed the Baby-Friendly Hospital Initiative (BFHI) to help bolster breastfeeding rates, but critics argue that some hospitals adhere to the program so rigidly that they undermine the wellbeing of mothers and their newborns, Carrie Arnold reports for the New York Times' "Parenting."

    New infographic: What parents want from low-acuity pediatric care

    The Baby-Friendly Hospital Initiative

    Experts generally agree that it's important for mothers to breastfeed their babies. Research has shown that breastfed babies have lower risks of developing asthma, allergies, childhood obesity, and gastrointestinal problems when they're older, Arnold reports.

    So, in response to declining breastfeeding rates, about 30 years ago, WHO and UNICEF launched BFHI. One of the program's tenets is WHO's "10 Steps to Successful Breastfeeding," a series of strategies meant to increase breastfeeding success, Arnold reports.

    These strategies include skin-to-skin care during the first hours of life, keeping a mother and baby in the same room for their entire hospital stay, no pacifiers to prevent nipple confusion, and no formula unless medically necessary.

    Later, an expert committee endorsed the 10 steps as useful in the U.S. health system, and an independent national authority called Baby-Friendly USA (BFUSA) was launched to certify hospitals as Baby-Friendly.

    Trish MacEnroe, CEO of BFUSA, said a number of studies have supported the 10 steps as the best way to increase breastfeeding rates.

    Criticisms of the program

    However, some experts have criticized the program's effectiveness, Arnold reports.

    One study published in October 2019 in the Journal of Pediatrics analyzed the number of women who breastfed nationwide in 2018 and found that mothers in Baby-Friendly hospitals weren't more likely to breastfeed than those in other hospitals.

    However, Alison Volpe Homes, a pediatrician at Dartmouth University, said measuring how Baby-Friendly hospitals impacted breastfeeding would require longer-term data than just one year.

    "It's not a good way to study the efficacy of Baby-Friendly," she said. "I don't know why anyone would set up a study that way," especially since just over 25% of all births occur in a Baby-Friendly hospital.

    Christie del Castillo-Hegyi, an ED physician in Arkansas, argued the problem with the BFHI isn't necessarily the program itself but rather how it's implemented at hospitals.

    For example, Arnold reports that BFUSA requires each hospital to decide how to fulfill WHO's 10 steps. According to Regina Cardaci, a nursing professor at New York University, this means hospitals might not have enough staff or adequate policies to ensure all of BFUSA's accreditation guidelines are safely met.

    The website for nonprofit Fed Is Best, a group that leads the critics of BFHI, features stories from parents and providers about babies who were dropped or almost suffocated by tired mothers attempting to breastfeed, Arnold reports. Cardaci said she's seen mothers in Baby-Friendly hospitals being given shots of Demerol, an opioid that can cause drowsiness, and then left alone to have skin-to-skin time and attempt to breastfeed their babies.

    MacEnroe said these stories are heartbreaking and that BFHI is meant to educate families on the benefits of breastfeeding. "Safety is the first priority," she said. "If a step can't be done safely, it shouldn't be done."

    According to del Castillo-Hegyi, some Baby-Friendly hospitals will still push mothers to exclusively breastfeed, even in instances where formula is needed.

    For example, Arnold reports that in February 2012, three-day-old Landon Johnson went into cardiac arrest from malnutrition and dehydration because his mother, Jillian, wasn't producing breastmilk. According to Jillian, nurses at the Baby-Friendly hospital wouldn't give Landon formula, but instead advised Jillian on herbs to use to increase her milk supply.

    After two weeks in the neonatal intensive care unit, Landon's parents turned off his life support once it was clear he had suffered irreversible and significant brain damage.

    "Exclusive breastfeeding is [BFUSA's] quality metric, not baby safety," del Castillo-Hegyi said. "And parents are being pushed and pressured, told that formula is poison, but they are not being told there are any risks to following these guidelines."

    Conflicting research

    The research on the 10 steps is somewhat conflicting, Arnold reports. For example, some studies have found that formula supplementation, which is not allowed in the BFHI, can bolster breastfeeding, as less stress could lead to a better breastmilk supply. However, other studies have not found that connection.

    In 2018, another study questioned how safe some of the 10 steps were, including skin-to-skin care, which has been linked to sudden infant death. However, a 2019 study published in the Journal of Pediatrics showed skin-to-skin care reduced the risk of suffocation. Meanwhile, a 2016 systematic review of 58 studies found the 10 steps improved breastfeeding initiation and exclusivity.

    Joel Bass, a pediatrician at Newton-Wellesley Hospital, who led a study that questioned the safety of some of the steps, said giving a new mother flexibility in breastfeeding is the most important part of breastfeeding success (Arnold, "Parenting," New York Times, 1/6).

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