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Are baby-friendly hospitals doing more harm than good?

The Baby-Friendly Hospital Initiative (BFHI) is a program developed in the 1990s by the World Health Organization to improve breastfeeding rates worldwide. Nowadays, it’s quite common to hear of hospitals refer to themselves as “baby-friendly,” meaning they’ve received an official certification by the BFHI. You’d assume that being called baby-friendly is a good thing—but a recent opinion piece is questioning is this practice is possibly doing more harm than good.

A baby-friendly hospital is one where certain practices are put in place and all maternity care staff have received very intensive structured breastfeeding education. The practices that these hospitals have standardized to promote breastfeeding are often referred to as the “10 steps.” You can read them all here, but they include practices like immediate skin-to-skin, rooming-in of moms and babies, and formula supplementation only when medically necessary.

We know from previous studies that these steps all increase breastfeeding rates—both the number of moms who start breastfeeding while in the hospital and those who keep breastfeeding for months afterward—and for every additional step that a hospital implements, breastfeeding rates climb higher and higher.

Sounds good, right? Well, most medical professionals would tend to agree, but a recent opinion in JAMA Pediatrics actually doesn’t think so. They take issue with a few practices, such as early skin-to-skin. They state that some babies may have issues breathing and some may have even died as a result of this practice. They also believe that rooming-in may leave some mothers who are too sedated to try unsafe sleeping practices, such as co-sleeping with their babies, which can lead to suffocation or falling out of the hospital bed. Another one of the 10 steps is avoiding pacifier use while in the hospital, which these authors disagree with since the American Academy of Pediatrics states they may actually help prevent SIDS (more on that later!). And lastly, they take issue with the recommendation that avoiding formula supplementation is always best.

Well. That makes baby-friendly sound like the worst possible idea, right? Fortunately for hospitals who’ve chosen this route, and the babies who are born in them, I think these authors get it completely wrong.

In no hospital should a woman who just gave birth be left unattended for that first hour after birth, when that first skin-to-skin contact is being done. During this time while the newborn is on Mom’s chest, her nurse should be frequently checking the baby’s positioning (Is the baby in a good position to breathe? Does he need a blanket moved off his face?) and vital signs (this includes how he is breathing). And any good Labor and Delivery nurse knows that a baby who appears unstable (or a mom, for that matter) isn’t safe for skin-to-skin and needs a different kind of care. Baby-friendly hospital training definitely teaches this.

In no hospital should a woman who is physically unfit to care for her baby be left alone to do rooming-in, and this includes the mom who is too sedated to lift her baby if she had a C-section under general anesthesia, for example. While many hospitals have done away with nurseries because rooming-in is the new norm, a nurse should always be available to care for a baby for moms in this category. Baby-friendly hospital training very clearly states this.

In no hospital should a mom ever be told that it is OK to co-sleep in fluffy, unsafe hospital beds. Baby-friendly hospitals don’t promote this practice. And while baby-friendly hospitals don’t use pacifiers, it is with the goal of getting breastfeeding established in the first few days postpartum, when SIDS is actually very rare. The idea that they should be given immediately because the American Academy of Pediatrics promotes them at 3 to 4 weeks postpartum seems a bit far-fetched to make this claim.

Lastly, baby-friendly hospitals absolutely use formula—when medically necessary. No one would withhold this from a baby if it were needed, but it should not be given on a whim as many hospitals historically tend to do. So I’m not quite sure where these authors get the idea that recommending moms breastfeed exclusively—unless formula is medically needed—is a bad idea, since we know doing this actually keeps babies breastfed longer.

My take-home message is this: The practices put in place by baby-friendly hospitals are good for babies. The doctors and nurses in these institutions are trained to implement these practices but also use common sense, which means not doing some when it’s safer to avoid them, too. To act like every hospital is rigidly enforcing these ideas is a bit sensational and takes away from the good we know this program has done. And if you see someone in a hospital doing it wrong (refusing to take a baby out of a room from a mom who is physically unstable, for example), speak up so it can be addressed—but don’t let that be a reason to shout from the roof tops that the BFHI is bad on all accounts.

It’s not time to throw the baby-friendly baby out with the bath water quite yet.

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