There are so many things wrong with the Baby Friendly Hospital Initiative (BFHI) that it’s hard to know where to start.
- The very name is a deliberate slap in the face to women who can’t or don’t wish to breastfeed. While breastfeeding has some benefits, in industrialized countries with clean water those benefits are trivial.
- There’s nothing particularly “baby friendly” about humiliating, harassing or inconveniencing mothers who want to formula feed or find that breastfeeding is not working for them.
- The BFHI is potentially deadly. The emphasis on 24 hour rooming in, even for mothers who don’t want it, has given hospitals cover to close well baby nurseries. That has led to babies being dropped out of bed or smothered by mothers who fell asleep while holding or nursing their babies.
- Neonatal hypernatremic dehydration, which occurs when women can’t make enough milk to fully nourish a newborn, may be rising as women are told (erroneously) that any formula supplementation, even temporary, is harmful to babies.
But the ultimate irony of the Baby Friendly Hospital Initative is that it DOESN’T work. Despite the expenditure of millions of dollars and countless healthcare provider hours, the BFHI doesn’t increase breastfeeding rates.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The BFHI is an abject failure on its own terms.[/pullquote]
This fact has been known for some time. I’ve been writing about it for years, and the professional lactivists I’ve tangled with in print have not been able to rebut it. Now, however, a comprehensive review of the BFHI literature shows that, on its own terms, the Baby Friendly Hospital Initiative is a spectacular failure.
The new paper is Baby-Friendly Hospital Initiative as an Intervention to Improve Breastfeeding Rates: A Review of the Literature was published in the current edition of the Journal of Midwifery and Women’s Health. The full study is available for free and I encourage you to read it.
The authors are clearly partisans of the program. One can almost feel sorry for them as they desperately search for benefits from the BFHI and find almost none.
When taken as a whole, the majority of research included for review supports the BFHI as an intervention to increase breastfeeding initiation, long-term breastfeeding duration, and increased breastfeeding exclusivity rates . However, it is notable that most research did not support the BFHI as an intervention that improves short-term breastfeeding duration rates. In addition, there is only a small difference in the number of studies showing that the BFHI increases breastfeeding initiation rates and those showing that it does not have an effect on initiation (4 vs 3, respectively).
What the authors mean is that when developing as well as developed countries are included, the BFHI has small benefits, but when considering only industrialized countries, the BFHI fails in most of its stated aims. The only area in which it seems to be successful is in increasing breastfeeding initiation rates while in the hospital. But most of that increase disappears when women leave the hospital. Since the goal of the BFHI is to increase the proportion of infants who are breastfed and the duration of breastfeeding, this is an indication of failure, not success. Yes, the BFI can harass women into attempting breastfeeding, but it doesn’t convince them to continue.
The authors try to put the best possible face on the dismal outcomes:
Considerable heterogeneity in definitions, design, methods, analysis, and outcomes was noted among studies; thus, it is not surprising that the results also are heterogeneous. Although it is difficult to reach definitive conclusions about the effectiveness of the BFHI based on the variety of research efforts to date, some trends do emerge.
A majority of the studies that assessed the effect of the BFHI did find that the program had a positive influence on breastfeeding outcomes. Of note, however, is that an increase in exclusive breastfeeding in the hospital is a criterion for Baby-Friendly certification. Thus, concluding that the intervention increases breastfeeding initiation employs a circular logic because the intervention itself cannot also be a measured outcome…
What can we take away from this paper.
The first surprise is that the issue has been studied so rarely. Like much of contemporary natural childbirth, the BFHI is, in Annandale and Clark’s formulation (What is gender? Feminist Theory and, the sociology of reproduction) the “largely unresearched antithesis of obstetrics.”
The lactation industry decided, without any scientific evidence, that the reason for less than 100% breastfeeding rates was “lack of support” for breastfeeding. Then they mandated specific actions that they believed constituted support, in the absence of scientific evidence that those actions were either supportive or effective in promoting breastfeeding. They created a credential (the BFHI) to award to hospitals who complied with their recommendations, with a price tag of over $11,000 per hospital.
Not only did they provide no evidence that these recommendations work (lecturing mothers about the benefits of breastfeeding, making formula virtually unavailable in hospitals, intimidating women who asked for formula, refusing supplementation under nearly every circumstance, and enforced rooming in policies), they failed to provide any possible mechanism of action by which the recommendations were going to increase breastfeeding rates.
At no point did they ask mothers why they couldn’t or wouldn’t breastfeed. They did not ask mothers who had given up breastfeeding before they had reached their stated goals why they stopped. That’s not surprising because the Initiative was designed to benefit the lactation industry, not women and not babies.
Having monetized the provision of lactation support by becoming paid lactation consultants, proponents of the BFHI made a critical error. They confused what was good for them — ever more opportunities to profit — with what was good for mothers. They never asked mothers what they wanted because as lactation consultants they believed they knew better than women themselves.
The BFHI is a classic industry sponsored initiative masquerading (as most industry initiatives do) as good for consumers. It’s not good for mothers; it’s not good for babies; and it doesn’t even work.
It time to abolish the BFHI. Hospitals should continue to employ lactation consultants, but they should be there to support women who want to breastfeed, not to “educate” those who don’t. Most importantly, lactation consultants and the breastfeeding industry should have NO control over hospital policies with regard to formula supplementation, rooming in or well baby nurseries.
The truth is that breastfeeding is simply not beneficial enough to spend millions of dollars and the efforts of millions of healthcare providers to promote it. Those scarce dollars and provider hours should be spent providing healthcare, not support for the breastfeeding industry — not least because the BFHI is an abject failure on its own terms.
