Reproductive Psychiatrist, Associate Professor of Psychiatry and OB/GYN, Oregon Health & Science University, Portland

Dr. Cirino reports no financial relationships relevant to this field of study.

SYNOPSIS: Data analysis from the 2018 Centers for Disease Control and Prevention Breastfeeding Report Card failed to show improvements in breastfeeding outcomes in Baby-Friendly facilities over statewide breastfeeding initiation programs.

SOURCE: Bass JL, Gartley T, Kleinman R. Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public policy implications. J Pediatr 2019; Oct. 10. [Online ahead of print].

The Baby-Friendly Hospital Initiative (BFHI) is a global program launched in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund with the aim to improve breastfeeding rates. To receive a Baby-Friendly designation, hospitals must implement the Ten Steps to Successful Breastfeeding and comply with the International Code of Marketing of Breast-Milk Substitutes. In 2019, 28% of births occurred in the more than 600 Baby-Friendly designated facilities in the United States. The 10 steps include, among other things: breastfeeding within an hour of birth, giving healthy infants no drink other than breast milk (i.e., no formula), eliminating pacifiers and bottles, and practicing rooming-in to “allow mothers and infants to remain together 24 hours a day.”¹ The guidelines were revised in 2018 “to respect maternal autonomy and avoid judgmental attitudes which could infringe on the mother’s dignity.”²

The primary objective of this study was to compare states with high penetrance of Baby-Friendly designated facilities to states with low penetrance of Baby-Friendly designated facilities in terms of targeted breastfeeding outcomes. Specifically, the researchers looked at the effect of the Baby-Friendly designation on in-hospital breastfeeding initiation, as well as breastfeeding outcomes at three, six, and 12 months post-discharge.

The authors analyzed data from the 2018 Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card referencing breastfeeding parameters in the 2015 birth cohort. The CDC annual Breastfeeding Report Card provides state-specific data on breastfeeding outcomes after discharge and includes WHO Baby-Friendly Hospital Initiative (BFHI) designation rates by state. These data rely on maternal recall when the children are between 19 and 35 months of age. Data collected included initiation percentages (low to high), any breastfeeding at six and 12 months, and exclusive breastfeeding at three and six months. Linear regression models were used to determine the strength of the association of breastfeeding initiation and Baby-Friendly penetrance and attainment of post-discharge breastfeeding rates. All hospital births from 50 states, three territories, and the District of Columbia were included in the study.

As expected, breastfeeding initiation, in itself, was significantly associated with all breastfeeding outcomes (P < 0.0001), including any breastfeeding at six and 12 months and exclusive breastfeeding at three and six months. This was the case in states with both high and low penetrance of Baby-Friendly facilities.

However, Baby-Friendly designated facilities did not demonstrate a significant association with any post-discharge breastfeeding outcomes over statewide programs. (Any breastfeeding at six or 12 months, P = 0.36 vs. exclusive breastfeeding through three or six months, P = 0.256). Further, there was no association between Baby-Friendly designation and breastfeeding initiation rates (P = 0.67).

The authors concluded that states with substantially fewer births at Baby-Friendly facilities, and that have high breastfeeding initiation rates, have had greater success in promoting breastfeeding after discharge. The researchers concluded that breastfeeding initiation is a more important outcome than breastfeeding exclusivity during the birth hospitalization. In summary, states with high Baby-Friendly designation penetrance did not demonstrate any positive post-discharge breastfeeding association.

Limitations to the study come from the data set itself. The Breastfeeding Report Card relies on maternal recall, was conducted by cell phone, and did not gather key demographic data such as race, ethnicity, poverty, and educational level.

COMMENTARY

With a global initiative backed by WHO and a name as benign as “Baby-Friendly,” many early opponents with concerns had little success in pushing back against the adoption of the BFHI movement. Many of us in the women’s mental health community have been particularly concerned with overly rigid enforcement of the 10 steps. We are routinely advocating for taking into consideration the mental health of the mother in the universal enforcement of such a policy.³

These guidelines do not have modifications in place for women with moderate or severe mental illness, acute postpartum hemorrhage or other perinatal complications, concurrent use of pain medication, or, until recently, a woman’s personal preference. Many facilities no longer have special care nurseries available, so in-hospital rooming-in is the standard expectation.

Sleep preservation in the first three weeks postpartum is one of the key strategies for prevention of severe postpartum episodes, and sleep deprivation has been implicated in the onset of severe postpartum psychiatric pathology.⁴ This high-risk period occurs during the same time period that the BFHI advocates for 24-hour-a-day “rooming together” and “giving infant no drink other than breast milk.”

The authors of this article are pediatricians who have published previously about their criticism of the BFHI.⁵ They cite recent concerns that the BFHI may increase adverse neonatal sentinel events, including suffocation injuries like sudden unexpected postnatal collapse (SUPC), newborn falls, and newborn dehydration and jaundice. SUPC occurs in otherwise-healthy term newborns, usually in the first 24 hours of life, and frequently is caused by the mother falling asleep during or after breastfeeding.⁶ This report raised the important question of whether bed-sharing, a practice that is discouraged at home, can be done safely in the hospital without medical supervision.⁷

This is the first evidence to date that shows a limitation in the effectiveness of the primary goal of the BFHI. These data alone do not prove that BFHI overall creates more risk than benefit to the mother-infant dyad. However, the fact that this “one-size-fits-all” initiative may not actually increase rates of breastfeeding in the general U.S. population, and may even hinder rates, should inform our in-hospital birthing practice moving forward.

REFERENCES

1. Baby-Friendly USA. The ten steps to successful breastfeeding. Available at: https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/. Accessed Jan. 16, 2020.
2. World Health Organization. Ten steps to successful breastfeeding (revised 2018). Available at: https://www.who.int/nutrition/bfhi/ten-steps/en/. Accessed Jan. 16, 2020.
3. MGH Center for Women’s Mental Health, Nonacs R. Does Baby-Friendly have to be mom-unfriendly? June 12, 2017. Available at: https://womensmentalhealth.org/posts/baby-friendly-mom-unfriendly/. Accessed Jan. 16, 2020.
4. Lewis KJS, Di Florio A, Forty L, et al. Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder. J Affect Disord 2018;225:624-629.
5. Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr 2016;170:923-924.
6. Gomez-Pomar E, Blubaugh R. The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. A critical review of the literature. J Perinatol 2018;38:623-632.
7. Steinhorn RH. Breastfeeding, Baby-Friendly, and safety: Getting the balance right. J Pediatr 2019; Dec. 3. [Online ahead of print].