I had a perfectly lovely time giving birth. Or, I guess, as lovely a time as a person can have while pushing out a 9-pound baby for 24 hours. Everyone we encountered at the hospital was efficient and kind, particularly the NICU nurses who tended to my daughter during her first night on the planet. The nurses on the maternity ward were great, too. They helped me pump that first evening, and then taught me how to breast-feed when my daughter graduated out of the NICU the next day. There was a lactation class, if I wanted to attend, and a roving lactation consultant came to my bedside and helped me several times while I got the hang of it.
I was surprised, then, to find out that the hospital where I gave birth was not “baby-friendly.” It seemed pretty friendly to my baby! But “baby-friendly” is a specific certification given out to hospitals that fulfill a 10-step rubric, which was developed by UNICEF and the World Health Organization in the early ’90s in order to encourage hospitals to urge mothers to breast-feed. To receive the “baby-friendly hospital” imprimatur, a maternity ward needs to practice rooming in (no bringing babies to the nursery), give babies nothing but breast milk unless medically indicated (no formula), and eschew pacifiers (no pacifiers).
The “baby-friendly” initiative is not new, but it has gained steam in the U.S. over the past few years. In 2007 only 2.9 percent of births happened in baby-friendly” hospitals. Currently 8.4 percent do, according to Baby-Friendly USA. As Brigid Schulte pointed out in the Washington Post, the adoption of “baby-friendly” measures at hospitals in and around Washington, D.C., has been somewhat controversial. Schulte writes that some mothers loved the new “baby-friendly” methods, while others felt “unduly pressured by staff members” to breast-feed. This is not a shocker—breast-feeding remains a touchy subject for many—but what I wanted to know was: Does science back up the “baby-friendly” method?
The short answer is not entirely. If the goal is prolonging the exclusivity and duration of breast-feeding, according to Dr. Michael Kramer, a professor of pediatrics, epidemiology, and biostatistics at McGill University, some of the 10 steps are sounder than others. Giving new mothers “instruction about techniques (latching, making sure the baby is swallowing rather than just nipple sucking), teaching them to feed on demand rather than on a schedule, and support for mothers who have problems” breast-feeding are the steps that have the strongest scientific support.
But there’s some evidence that supplementary early formula use helps mothers breast-feed longer, because it alleviates some of their stress. There’s also evidence that restricting pacifiers increases formula use. A study of more than 2,000 babies at a hospital in Oregon following “baby-friendly” guidelines found that “the rate of exclusive breastfeeding on the mother-baby unit decreased significantly after pacifiers were restricted.” Additionally, the number of infants receiving supplemental formula went up 10 percentage points when binkies became verboten. (Though, as I said, supplemental formula might not be a bad thing.) The study’s authors add that pacifier use is also associated with a decreased risk of sudden infant death syndrome, or SIDS.
But there’s an even more fundamental question: In a developed country like the U.S., is breast-feeding really as important as some of its more full-throated advocates make it out to be? Should its promotion be central to a maternity ward’s mission? A recent study of siblings, one who was breast-fed and the other who was not, showed that the long-term health benefits of breast-feeding may have been overstated. Joan Wolf, the Texas A&M professor and author of Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood, says that “Under the best of circumstances, [the benefits of breast-feeding] are extremely small and they can be offset by the costs to the mother.”* Dr. Kramer, who is a proponent of breast-feeding, believes it’s possible to go too far. "It’s one thing to encourage it, it’s another thing to make women feel guilty if they don’t want to or can’t."
I asked Gladys Vallespir Ellett, the coordinator for parent education at the NYU Langone Medical Center, an official “baby-friendly hospital,” about some of the findings that don’t back up the “baby-friendly” approach, like the pacifier research. She said she wasn’t familiar with them, but that the “baby-friendly” designation is so much more than that. “It’s a whole philosophy,” she explained over the phone. Nurses go through a minimum of 20 hours of training for breast-feeding, and 92 percent of them are certified lactation counselors. Another part of securing the “baby-friendly” certification is getting rid of the gift bags that formula companies used to give to the hospital. (NYU purchases formula now.)
How does NYU’s “baby-friendly” philosophy play out for new moms and dads? Overall, the parents I talked to had positive experiences. However, one mom said she felt the pressure to breast-feed was pretty overwhelming—even though it was actually something she wanted to do. “I had a lot of problems breastfeeding and they were bound and determined that no formula would be had if they had any say about it,” she wrote in an email. “I understand what they were doing but man, that was rough.”
Other parents felt like they were shamed about putting their babies in the nursery. One dad, who said they had a good experience overall, reported, “After 36 hours of my wife being awake, ‘baby friendly NYU’ sent me home because visitors weren't allowed and tried to make my sleep-deprived and terrified wife care for a newborn by herself. She felt guilty when she took her to the nursery, only to discover that all the babies were there.”
I asked Vallespir Ellett about what happens if a mother does not want to breast-feed or if she wants her baby taken to the nursery so she can rest. “Those are her choices,” Vallespir Ellett said. “But in a baby-friendly institution, we just want her to understand—and you know, what does understand mean?—we want to give her the knowledge about breast-feeding. That there’s evidence that supports the practice of breast-feeding as the best way to feed your baby.” If a mother wants to send her child to the nursery, “We’ll say, we know you’re exhausted, so what can we do to help you?” instead of sending your kid to the nursery.
This message can make some moms feel less supported than cornered, as if sending their babies to the nursery were some extreme last step. While the nurses have the best intentions, their attempt to make a new mom “understand” can feel judgmental—the first judgment of many to come. One mom told me that, after the birth of her second child, she thought NYU had gotten rid of its nursery. “I honestly didn’t even think I had the option of the nursery for most of the first night, until my roommate, an Orthodox woman who had just had her sixth or seventh kid, basically stood up to the nurse and said, ‘You are taking this baby. I know all about being a mom to a newborn, and you are taking this baby to the nursery.’ Still, I was too chickenshit to ask.”
It’s worth noting here that the moms and dads interviewed for this article are all college-educated and fairly empowered consumers of health care. But not all new parents are. Shelly Lopez Gray, a labor and delivery nurse and international board-certified lactation consultant in Texas who runs the website Adventures of a Labor Nurse, says that before the hospitals she worked at started trying to get “baby-friendly” certification, they discouraged new moms from breast-feeding. “A ton of hospitals provide no breast-feeding support at all. They routinely take the babies away from the moms for four to six hours” right after birth, Gray says.
As a nurse, Gray’s experience of implementing “baby-friendly” practices has been wonderful. She’s experienced little pushback from new moms, who are mostly just grateful. “It’s a different culture” than in New York, Gray says. The problem is not that there’s overt pressure to breast-feed from all corners, like there is in New York or D.C. The problem is that there’s no support for breast-feeding at all.
Still, despite the pride that its advocates clearly take in the “baby-friendly” designation, it is not gospel. Though it has been shown to increase rates of breast-feeding, Dr. Kramer says that the individual requirements for the certification have not all been disaggregated and studied. “There’s kind of a pride, a feeling of we know this works overall as a package, so let’s get the certification rather than look at it under the microscope. There’s a lot of religion behind it, like it was handed down like the Ten Commandments.”
Of course, a mother who wants to breast-feed should be fully supported in the first days of her baby’s life. There’s no argument about that. But there are downsides to the “baby-friendly” push, a doctrinaire fervor about a baby’s first days, communicated by medical professionals, that can make it seem like if a new parent makes any wrong move, her child is doomed. I know my daughter was not damaged because she spent her first night in the NICU instead of against my breast, skin to skin. In their eagerness to be baby-friendly, some of these hospitals have become mother-unfriendly, and that’s not good for anyone.
*Correction, Oct. 9, 2014: This piece originally misidentified Is Breast Best? author Joan Wolf as Joan Williams.