A new paper in JAMA Pediatrics is the latest in a series of critiques of the so-called "baby friendly" hospital movement. Previously, the global pro-breastfeeding initiative has been questioned for its effectiveness and for its unfair treatment of new mothers. Now, doctors are questioning its safety.
The Baby-Friendly Hospital Initiative was launched by UNICEF and the World Health Organization in 1991 in order to improve breastfeeding rates. Participating hospitals agree to follow ten rules which include rooming-in (having babies sleep next to mom instead of in nurseries), a ban a pacifiers, and only using formula when medically necessary. In 2010, the U.S. Department of Health and Human Services endorsed the initiative, and since then the number of participating hospitals has steadily increased to a rate of nearly 17 percent of U.S. hospitals, according to BFHI accrediting organization Baby-Friendly USA.
Writing for JAMA Pediatrics, pediatricians Joel L. Bass, Tina Gartley, and Ronald Kleinman express their unease with the potentially dangerous, and sometimes fatal, consequences for babies delivered at baby-friendly hospitals. “Unfortunately, there is now emerging evidence that full compliance with the 10 steps of the initiative may inadvertently be promoting potentially hazardous practices and/or having counterproductive outcomes,” they write.
Their first area of concern is the initiative's requirement for skin-to-skin contact between mother and child directly after birth until the completion of the first feeding, and to encourage skin-to-skin contact throughout the hospital stay. The problem is not the skin-to-skin contact itself, which has documented benefits, but the fact that mother and child are often left unsupervised during this time. Studies show that with unsupervised skin-to-skin contact comes an increased risk of Sudden Unexpected Postnatal Collapse (SUPC), “a condition in which a previously vigorous, spontaneously breathing infant who had a five-minute Apgar of 8 or more, unexpectedly becomes apneic, often necessitating full resuscitation.” In 2013, the American Academy of Pediatrics put out a report cautioning hospitals to balance skin-to-skin contact with the implementation of safe sleeping habits for the newborn as well as ongoing monitoring of the infants. They pointed to a Swedish study that found that 15 of 26 newborns who experienced SUPC, and had no underlying conditions, did so while in a “prone skin-to-skin” position. Also, 13 of the newborns who experienced SUPC were breastfeeding without supervision of a nurse or doctor during their first two hours of life.
Other concerns in the JAMA paper include the encouragement for rooming-in, even when the mother is exhausted or sedated. They believe this can lead to unsafe conditions for the newborn, and that parents, thinking that such sleep-arrangements were hospital-approved, may continue sleeping in such a manner once they return home. Also, they question whether supplementation with formula should really be banned, as there is no hard evidence linking early formula use to a decreased likelihood of breastfeeding further down the line. In fact, one study suggests that early formula use might help increase breastfeeding rates by reducing stress among new moms while they wait for their milk to come in. Anecdotally, I know a lot of women who've found a tremendous amount of relief in using a little formula during the first couple of days postpartum. And I know others who didn’t use formula during this period per the advice of their lactation consultants, and suffered a great deal.
The question of pacifiers comes up in the JAMA paper, as well. While baby-friendly hospitals require a ban on pacifier use—which they believe can confuse newborns and discourage breastfeeding—pacifier use has been linked to a reduced risk of sudden infant death syndrome, or SIDS. As the authors explain, the fact that a “substantial amount” of SUPCs, which can lead to SIDS, happen during the first few weeks of life makes this ban illogical.
They end the paper by arguing that the Office of the Surgeon General should reconsider its call for an acceleration of the implementation of the Baby-Friendly Hospital Initiative in the United States. “If government and accreditation agencies wish to encourage and support breastfeeding, their focus should shift from monitoring Baby-Friendly practices and breastfeeding exclusivity to monitoring breastfeeding initiation rates coupled with evidence of lactation support both during and after the hospital stay. More attention should also be placed on ensuring compliance with established safe sleep programs, emphasizing the need to integrate safe sleep practices with breastfeeding.”
In other words, it’s possible to encourage breastfeeding without making breastfeeding the sole focus of the maternity ward—an objective that can all too easily come at the expense of a woman’s autonomy and an infant’s health. What families need is hospital-based breastfeeding support that is responsive to the physical and psychological needs of the mom and doesn’t prioritize feeding over other aspects of an infant’s health. Such a flexible approach will be less easy to implement than the one-size-fits all, checklist-friendly structure of the baby-friendly movement, but it’s more likely to serve mother and child well.