What’s Wrong With the Baby Friendly Hospital Initiative? I’m Glad You Asked.
For those who are no longer entrenched in the newborn and infant stages, the Baby Friendly Hospital Initiative “BFHI” was a global initiative launched by the World Health Organization and United Nations Children’s Fund in the early 1990’s to “encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother-baby bonding. It recognizes and awards birthing facilities who successfully implement the Ten Steps to Successful Breastfeeding (i) and the International Code of Marketing of Breast-milk Substitutes (ii).” Essentially, it is a program that is supposed to encourage and promote breastfeeding as well as skin-to-skin bonding. Unfortunately, what started off as a good intention (we all know what the road to hell is paved with), has become a euphemism for a campaign that has sacrificed and marginalized maternal physical and mental health, and the health of newborns, for the sake of its’ bottom line.
The bottom line of the BFHI is to make as many mothers breastfeed as possible. In order to do this, the BFHI requires designated facilities to follow it’s ten-step recommendation:
Have a written breastfeeding policy that is routinely communicated to all health care staff.
Train all health care staff in the skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within one hour of birth.
Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
Give infants no food or drink other than breast-milk, unless medically indicated.
Practice rooming in – allow mothers and infants to remain together 24 hours a day.
Encourage breastfeeding on demand.
Give no pacifiers or artificial nipples to breastfeeding infants.
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.
Let me preface this by stating that I am not anti-breastfeeding. If you want to do it, great. My problem with the BFHI is that it has taken the goal of breastfeeding to an extreme, making it the priority above all else, including the health of the baby and the mother. Because of this, the BFHI is not really “mother-friendly” at all, and even not as “baby friendly” as it claims.
My biggest issues with the BFHI are as follows. First, it does not support feeding choice, despite what may be right for the baby or for the mother. It is one thing to tell the mother about the benefits of breastfeeding and to have lactation support in the hospital. It is completely another to hide formula and to force new mothers who bottle feed to sign waivers. We trust mothers to make their own choices about sleeping arrangements, clothing, diapering, and education. It is ridiculously patronizing to refuse to let them make their own choices about feeding.
Second, many hospitals, in a frenzied rush to receive the BFHI designation, have done away with their well-baby nurseries. The ostensible reason for this move is because “babies and mothers sleep better when they room in”. I don’t care what any study allegedly says, go ahead and re-read that last line again with a straight face. (When they told this to my husband and I for our third child’s birth we laughed so hard we almost fell out of our chairs at the hospital orientation). Of course, hospitals are more than happy to jump on the no-nursery bandwagon, because it means they can cut back staff and services and save money, all in the name of the insidiously named BFHI. In addition, hospitals receive free grant money, to the tune of millions of dollars, to push these policies.
I’ve had enough arguments online to know that a decent portion of women don’t agree with my assertions about the BFHI. So before you get your (mesh) panties in a knot, let me address the usual claptrap that gets tossed about.
First, I don’t have any issue with rooming in. Again, if you want to do it, good for you. But again it all comes down to choice. You may not want to use the nursery, but that does not mean I should be prevented from using one.
In particular, as a person who has had three c-sections, including one very bad experience, I can attest that the nursery is a necessity, not a luxury. People like to argue that you will be exhausted with the newborn anyways, so you’d better get practicing asap. Why? For what reason, in America at least, are women expected to be superheroes that pop out an eight pound human being and then go about their business like nothing else has happened? In other countries, the mother is allowed days, sometimes a month to recuperate. Moreover, there is a difference between the normal exhaustion that accompanies parents the first few weeks of a newborn life and the exhaustion that occurs after hours of labor and/or a full abdominal surgery. In the case of those women who have had c-sections (which can be upwards of a third of American women), they are taking various narcotics for pain, including morphine and opioids. Guess what the first common side effects listed for these drugs are? That’s right: weakness, dizziness, sleepiness, and sedation. Yet, we are going to hand a newborn to one of these mothers and leave her alone to fight through the drug-induced exhaustion to care for the baby.
Indeed, the health care industry is starting to see the problems with this policy. In an article published in JAMA last month, doctors finally admitted that strict adherence to the BFHI ten-steps may “inadvertently promote potentially hazardous practices”. In particular, the article cautioned that the policy “may inadvertently result in a potentially exhausted and sedated mother being persuaded to feed her infant while she is in bed overnight, when she is not physically able to do so safely.” The risks include a newborn falling out of the bed under these circumstances. (As someone who almost dropped my son on this last go-round due to these practices, I can attest that this does happen).
At this point, let me address a favorite mouthpiece of the naysayers: no, nurses are not there to watch the baby while the mother rests. This is the entire point of well-baby nurseries, which the BFHI is helping to eliminate. Nurses are there to check vitals on the mom and the baby, to ensure that no complications are occurring after the birth with either patient. If nurses are focused solely on the breastfeeding aspect, then they are focused on the wrong thing. Of course, this is becoming the case in more and more BFHI hospitals, as I recently experienced. Because the nurses were hyper-concentrated on whether I was breastfeeding (I wasn’t), and their insistence that I should be, they did not focus on my health, missing complications which almost cost me my life.
As an additional counter argument to one that is often raised: not everyone has family or spouses available to help, either. If you don’t believe me, have a second child. Where is your spouse now? Oh yeah, he’s home with the other kid. Not that he can do much if you are not supplementing or formula feeding.
Which brings me to my final major issue with the BFHI: not all babies benefit from being breastfed entirely or only exclusively after birth. Breastfeeding-only proponents would have you believe that all mothers are able to produce breastmilk at the outset, without any complications. This is patently not true. One only has to glance down the breastfeeding aisle at Babies R Us replete with nipple shields, lactation aids, and stimulating devices to see that this is not the case. Some doctors estimate that the proportion of women who can’t breastfeed is around 15%, as they suffer from conditions such as insufficient glandular tissue. But this doesn’t even take into account women who have suffered from cancer or other conditions that may prevent lactation, let alone women who may eventually start lactating but may not initially, due to premature birth, stressful births, or other conditions.
All of these issues with breastmilk contraindicate a policy that rigidly refuses any supplementation with formula. In fact, some babies who are not getting enough milk in the first few days suffer from jaundice or hypoglycemia, which can in turn affect their neurological growth down the line. In the simplest terms, the BFHI’s policy of refusing formula, even supplementation, to ensure exclusively breastfed newborns, can cause brain damage in these infants. How is that even acceptable?
Of course, I’m not a nurse. So don’t take my word for it. But I did manage to find an anonymous nursing site where OB nurses are expressing concern over these very same policies. At least one nurse has expressed concern that she wondered “how many babies are going hungry while we reassure mothers that their babies are being fed, when in reality they are not.”
That same nurse acknowledged that “Most moms haven’t had adequate sleep since before labor and some are taking narcotics for pain. This is not a safe situation. Most babies are not hurt, but the risk is definitely there. Our fall risk assessments that we complete every four hours even acknowledge that a tired, breastfeeding mother has a higher risk of dropping her baby. Even though adverse outcomes like falls are infrequent, the fact that we are sending new mothers home in states of exhaustion is not acceptable. Most women do not have help at home, and the hospital is the only place they do have some assistance. Instead, they are looked down upon when they ask for it.” Id.
There is an even greater problem with pushing breastfeeding to a point of mental and physical exhaustion: it is going to cause even higher numbers of mothers with post-partum depression and anxiety. This concept is not a stretch: we expect mothers to give birth, stay awake for days afterward to exclusively breastfeed, and to do it alone. This routine would not be healthy for anyone, let alone new mothers.
Because of this, the BFHI has become a hindrance to the health-care of women and newborns. It is the very parable of a good intention that has lost its way. The current practices are neither mother-friendly, nor baby-friendly, despite what the name states. A better policy would be one that supports breastfeeding, while recognizing that it is not the best feeding method for all families. It would be a policy that sees mothers as more than a feeding vessel, and remembers that she is still a patient, too. It would be an initiative which recognizes that the best outcome for a baby flows directly from the physical and mental well-being of its mother, and puts in place steps that value this outcome above any feeding or sleeping methods.
I am mediocre mom!
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