Evidence is Clear: Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in the US and Closes Breastfeeding Disparities
By Melissa Bartick, MD, MSc and Nathan Nickel, MPH, PhD
The US Preventative Services Task Force (USPSTF) published its recommendations regarding breastfeeding promotion in the October 25, 2016 issue of JAMA, recommending individual efforts at breastfeeding promotion, but pointedly noting that systemic promotion efforts, such as the Baby-Friendly Hospital Initiative (BFHI), were outside its scope. The accompanying literature review, performed by the USPSTF team, purposely looked only at two trials of BFHI and a few randomized trials of its component Ten Steps, and concluded there was mixed evidence to support BFHI. The two trials they reviewed on BFHI both supported its efficacy, at least in less educated mothers (here and here). One of the BFHI trials they reviewed was an observational trial, and the other was a before-and-after trial, yet several other US trials with similar methodologies exist which showed positive outcomes, but these were not even mentioned in the literature review. For example, the literature review did not include this national trial showing a correlation of BFHI with increased breastfeeding rates and excluded national data from the CDC showing rising breastfeeding rates as percentage of live births in Baby-Friendly hospitals rose. The literature review acknowledged that other studies supported the effectiveness of BFHI. However, an accompanying editorial by Flaherman and von Kohorn concluded that interventions such as BFHI “should be reconsidered until good-quality evidence that these interventions are safe and effective.”
Despite the weak literature review, the editorial’s surprising conclusion can in no way be drawn from the evidence presented by the USPSTF, let alone the evidence as a whole. Yet this editorial is what is garnering the most media attention. Interestingly, the editorial does support previous research by one of its authors, Valerie Flaherman, who found that small amounts of formula help women breastfeed longer. This finding, which contradicts previous evidence (here and here) that non-indicated supplemental formula is a strongly associated with breastfeeding failure, would negate Step 6 of the Baby-Friendly Hospital Initiative, “to give no other food or drink besides breast milk without a medical indication.” One of the co-authors of Flaherman’s study disclosed that he worked for several formula companies. Because Flaherman is still conducting similar government-funded research on formula supplementation of breastfed infants, which is incompatible with Baby-Friendly, JAMA should have chosen an editorialist who could be objective about the weight of the evidence on Baby-Friendly as well as include an editorial with an opposing viewpoint in the same publication– especially given the widespread endorsement of the Ten Steps among major US and world medical organizations. Read the rest of this entry »
It’s become routine: a big anti-breastfeeding piece comes out in a major publication like the New York Times, or The Atlantic or Time. A mom complains how the benefits of breastfeeding are overrated, how breastfeeding is being forced on people, how moms are feeling shamed into breastfeeding or risk being bad mothers.
Let’s listen to these moms for a minute. Regardless of what we breastfeeding people are actually saying, this is what moms are hearing. We need to ask ourselves, why do they hear this message?
Here’s why: Moms experience the “lactivist.” To the uninitiated, the term “lactivist” equals zealot. Someone who believes that breastfeeding is the answer for every mom in every situation, someone who is inflexible, incapable of listening to a mom’s individual needs and desires.
Any woman who’s just had a baby would probably see a “lactivist” as The Enemy. Imaging yourself as that new mom. You are not thinking the “lactivist” is a savior in a white cape who’s going to defend you from evil hospitals who want to give your baby formula. She’s someone who’s going to push everyone out of the way and make you breastfeed, regardless of your own trials and tribulations, your pain, your exhaustion. She’d not there to help you. She’s there to advance her own agenda of world breastfeeding hegemony.
And, if a mom doesn’t actually encounter a self-described lactivist, she might see the effects. All it takes is a journalist-mom who hears one resentful nurse say “we’re not allowed to teach formula feeding,” and you’ve generated enough anger for a full page New York Times op-ed. This journalist then misrepresents the scientific evidence for the entire world to prove her point that the so-called “Breastfeeding Nazis” are out to get you, and it’s just not worth it, because breastfeeding’s not even all that good for your baby anyway.
We must be careful with our rhetoric, and treat every single mom with compassion and understanding. We must take care in how we train our staff and how that staff communicates to patients. Breastfeeding people all know that it’s required to teach moms how to formula feed, and staff must feel inside that this is valuable information for many moms.
It only takes one “lactivist” to piss off a journalist. You never know who might turn around and write that next full page op-ed for the New York Times.
So please, let’s stop using the word “lactivist.” Better yet, let’s replace zealotry with compassion and understanding, and meet every mom where she is. And if we see zealotry in our colleagues, let’s gently remind them that this may be how we got to that Time magazine cover and New York Times op-ed. That is the only way we will stop this negative press.
Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School.
Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.
Some public health messages everyone can agree with: Never drink and drive. Always put your infant in a car seat. Other public health messages seem to ask us to do the impossible: Teenagers must never have sex. Mothers must never share a bed with their infants.
Advice around the US urges parents never to bed share, reinforced by the official stance of the American Academy of Pediatrics. Scary ads abound. One ad shows a queen-sized bed with a headstone in place of headboard reading “For too many babies last year, this was their final resting place.” Another shows a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad says “Your baby belongs in a crib, not a casket.”
The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.1-4 Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation.5 According to a 2010 study of nearly 5,000 US mothers, “in a possible attempt to avoid bed sharing, 55% of mothers feed their babies at night on chairs, recliners or sofas. Forty–four percent (25% of the sample) admit that they [are] falling asleep with their babies in these locations.”6 This is truly disturbing.
The advice to never sleep with your baby has backfired in the worst possible way. Rather than preventing deaths, this advice is probably even increasing deaths. In another study, parents of two SIDS infants who coslept on a sofa did so because they had been advised against bringing their infants into bed but had not realized the dangers of sleeping on a sofa.5 In fact, deaths from SIDS in parental beds has halved in the UK from 1984-2004, but there has been a rise of deaths from cosleeping on sofas.7 Read the rest of this entry »
Fact or fiction: Is breastfeeding actually linked with a lower risk of childhood obesity? The common thinking for the past several years has been “yes,” based on comprehensive analyses from the US Agency for Healthcare Research and Quality and the World Health Organization. However, two recent articles have disputed these conclusions. Considerable media attention has surrounded new data from the Promotion of Breastfeeding Intervention Trial (PROBIT), published in the Journal of the American Medical Association (JAMA) on March 13, and in a January 31 article in the New England Journal of Medicine (NEJM) on obesity myths by Casazza et al. We discuss both articles’ conclusions, as the public tries to make sense of all the conflicting information. Read the rest of this entry »