Breastfeeding Medicine

Physicians blogging about breastfeeding

ABM’s Model Maternity Policy Supportive of Breastfeeding: More than just a protocol revision

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The new ABM Clinical Protocol #7 could have just been the revision of an outdated protocol. That was my idea when I received Wendy Brodribb’s invitation to help update the 2011 Breastfeeding Hospital Policy protocol. Being the national coordinator of the Baby-Friendly Initiative in Spain, a member of the BFHI coordinator’s network, and a practicing pediatrician, I am fully aware of the importance of a breastfeeding supportive policy in hospitals, so I was passionate about being part of the update of this specific protocol. I knew the subject, it was just an update and it was also about teamwork with great colleagues: Melissa Bartick, Paula Schreck and Cadey Harrell and the supervision of the ABM protocol committee. Before me I saw an idyllic task that seemed simple and rewarding even for a non-native English speaker. Thus I gladly accepted the challenge and was grateful to be able to contribute to ABM’s mission.

Slide1However, I had not envisioned the ambitious team we had formed! Soon it was clear that my “simply reviewing and updating” plan was to become an absorbing, demanding, and exciting piece of work to produce a completely new and comprehensive protocol. The last two months trying to meet the deadline were exhausting but really exciting with transoceanic telephone conversations and chats, and continuous emails. Working on the same document while adjusting our different timelines in mid-August (we took turns to write fervently while the others were sleeping) was really fun!

The social inequalities and structural determinants that result in health injustice are the same that interfere with a happy breastfeeding experience. These interferences and the lack of adequate protection and support for breastfeeding unjustly burdens the health of women and infants (the most vulnerable part of society) at risk, especially if they belong to disadvantaged classes or countries with the least resources. Health professionals and health care facilities can be part of the problem, or they may become part of the solution.

We need to remember that many mother-infant health care practices were introduced in maternity hospitals at the beginning of the last century without any evidence to support them. Practices that have become routines such as mother and child separation after birth (for bathing, examining or dressing the newborn in detriment of skin-to-skin contact), early cutting of the umbilical cord, administering infants unneeded and early supplements of glucose or formula, caring for the newborn in nurseries or using dummies and bottles, were rapidly adopted without any scientific basis in maternities around the planet.

Slide2The implementation of this type of care can be considered (as it was said of formula feeding) the largest experiment carried out on human beings without controls. In spite of it all, after being facilitated by certain social factors and reinforced by mercantile interests, this type of care has become deeply integrated in the culture of health-care facilities and in the society at large. So much so that despite the evidence accumulated over the years against it, there are still many professionals resisting to change and continuing to demand “irrefutable” evidence to implement evidence based, effective and safe-proven strategies such as the joint WHO-UNICEF’s Baby Friendly Hospital Initiative (BFHI). This protocol is addressed to all institutions that seek to implement best practices in perinatal care, knowledgeable as they may be, that the care a mother and her newborn receive from pregnancy, during childbirth and in the postpartum period will influence their success with breastfeeding, their health and their lives.

We have written a renewed, inclusive protocol, in which all realities may be accommodated and in which mothers and newborns are the center. We strived to make it inclusive as nowadays Motherhood comes in the form of very different realities. We even contacted personally the authors of the trasgender articles we cite, to be sure we were making the correct assertions. Therefore, recognizing that breastfeeding is the norm, this ABM Maternity Policy is inclusive and ensures adequate support for parents who use supplements, those who feed exclusively on substitutes or expressed breast milk, transgender parents who chestfeed and parents breastfeeding their adopted infants.

Slide3It couldn’t just be a Breastfeeding Policy. There are so many issues such as cord clamping or the type of pain control measures and the support a woman receives at the time of delivery whose effects on breastfeeding have only recently been identified!  The protocol was going to get big, but we agreed that those aspects had to be included! It had to be a Model maternity Policy supportive of breastfeeding and not just a Breastfeeding Policy because the way perinatal care is offered greatly affects breastfeeding and maternal and child health!

As required for every ABM protocol, a bibliography was constructed by conducting a review of the bibliography published since 2012. We extended our systematic search in PUBMED and LILACs to articles in English, French, Portuguese and Spanish. We searched the evidence for each of the 10 Steps, the International Code of Marketing of Substitutes, early care for non-breastfeeding mothers, and humanized childbirth care. We included for review every related ABM protocol and the most recent related documents published by WHO, UNICEF and the EU Public Health Authorities. This resulted in more than 1000 abstracts from which, after discarding the lowest quality ones, we selected 302 publications that were thoroughly reviewed and summarized. A novelty was that the team decided on the adoption of a new system of gradation of evidence for which we had to obtain the approval of the protocol committee: the Oxford Center for Evidence-Based Medicine (OCEBM) Criteria. This gradation system is current and comprehensive and allows for the gradation of the different aspects that need to be addressed in this protocol. The OCEBM recognizes that it is necessary to go beyond clinical trials for the analysis of evidence that does not refer to therapeutic problems and that for some types of evidence observational studies even anecdotes can sometimes offer definitive evidence (I advise interested parties to visit The timing of this update in our assessment of levels of evidence worked well for the protocol committee, which was also seeking to improve guidelines now that the U.S.-based National Guidelines Clearinghouse no longer exists. All the assertions made in this Maternity policy supportive of breastfeeding protocol are supported by evidence mostly at level 1 or 2, or are recommendations endorsed by prestigious international organizations such as ABM, WHO or UNICEF. Another novelty was the use of GRADECERQual for the qualitative evidence that has been included in the protocol.

The protocol is organized chronologically from pregnancy to lactation for the sake of clarity of implementation and includes the requirement of abiding by the International Code of Marketing of Breast Milk Substitutes as an integral part of providing quality perinatal care and avoiding vested interests.

This protocol not only provide maternities with recommendations for implementing best quality health care practices; this protocol specifically calls for ensuring respectful recommendations, including nondiscriminatory care practiced with cultural humility for all parents and newborns to guarantee that care and support offered to mothers and families is timely, appropriate and sensitive to their needs, honors privacy and informed choice and secures coordination among providers.

And finally, this protocol does not forget that health care workers may also be parents and their breastfeeding rights need to be protected, and therefore includes the recommendation that maternities facilitate breastfeeding for their workers.

I am writing this on Thanksgiving day, it is not a holiday in Spain, but I feel I need to say I am grateful to have been part of this team and to have been able to contribute to this special ABM protocol. It has been real hard work but the whole team is proud of it. We hope that it gets wide implementation and helps maternities all over the world to offer the best care for mothers and infants. This is the type of care every woman and infant deserve and which can make a positive difference in their lives!

Maria-Teresa (Maite) Hernández-Aguilar, MD, MPH, PhD, IBCLC is a physician at the  Dr Peset Breastfeeding Unit, Valencia, Spain and  National Coordinator of the Baby-Friendly Initiative in Spain (IHAN).

Blog posts reflect the opinions of individual authors, not ABM as a whole.

Written by amalactancia

November 27, 2018 at 5:28 pm

5 Responses

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  1. Thank you, Dr. Hernandez-Aguilar, and everyone who participated in this updated protocol. I have already shared it w some physicians in my area. I have to wonder, however, why there is no mention of IBCLCs. IBCLCs have more education/clinical training than any other breastfeeding “helpers”, are members of the health care team, are tasked w clinical management of breastfeeding. It is curious that they are not included in the list of those responsible to help moms in and out of hospital.

    Peggy Hinkle

    November 28, 2018 at 12:57 am

    • Dear Peggy, the authors are well aware of the important role that IBCLCs play supporting and protecting breastfeeding from pregnancy and far beyond the perinatal period, some of us being IBCLCs ourselves. It was a difficult decision but we finally opted to include IBCLCs in the group named “lactation specialists”. We selected this term so that it could include different situations in different settings and countries where there are no IBCLCs, IBCLCs are not recognized by Health Care Systems’ accreditations, or where other types of certifications for lactation specialists are recognized.
      We sincerely hope that this clarification is helpful for you and for all IBCLCs.


      December 8, 2018 at 3:21 pm

  2. This is an incredibly comprehensive policy update! Thank you for all your hard work. I will be sharing this broadly with hopsitals in Texas today!


    November 28, 2018 at 9:33 am

  3. ABMs new “Model Maternity Policy Supportive of Breastfeeding” is a wonderful tool for improving maternity care practices. Thank you so much for this valuable resource. The addition of the IBCLC, especially the IBCLC-to-patient staffing ratio from the US Lactation Consultant Association would have been a valuable addition. However, of even more concern is the editorial by Dr. Eidelman regarding the negation of the Baby Friendly Hospital Initiative (BFHI). His discrediting of the BFHI is most distressing, especially since the Model Policy specially states that, “This protocol includes all the elements covered by the BFHI ‘‘Global Criteria,’’ because the BFHI is, at present, the best model with proven efficacy. As so well stated by Dr. Hernández-Aguilar in this blog, “The OCEBM recognizes that it is necessary to go beyond clinical trials for the analysis of evidence that does not refer to therapeutic problems and that for some types of evidence observational studies even anecdotes can sometimes offer definitive evidence.” What a shame that there seems to be such a disconnect.

    Marsha Walker, RN, IBCLC

    November 28, 2018 at 1:00 pm

  4. Good to be associated with ABM as a Breastfeeding advocate to update my knowledge

    Dr.Kannaiahgari kesavulu

    February 2, 2019 at 8:07 am

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