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.
