The U.S. Preventive Services Task Force, a federally appointed panel of health experts, has just updated its recommendations on primary care interventions to support breast-feeding, and it’s bad news for the the Baby-Friendly Hospital Initiative. Based on a comprehensive review of recent studies, it found that such system-level interventions—which demand a one-size-fits-all approach to breast-feeding support—are far less effective than individual-level interventions in boosting breast-feeding rates and duration.
The task force’s evidence report and recommendations were recently published in the Journal of the American Medical Association, along with an accompanying editorial by physicians Valerie Flaherman and Isabelle Von Kohorn, who rely on data from the report to more thoroughly critique system-level interventions.
Flaherman and Von Kohorn’s primary concern with the BFHI-style initiatives is that they aren’t working. Whereas the “studies reported the positive effect that individual-level support provides to a breastfeeding dyad, particularly if support is given at multiple time points … there was no consistent association between system-level interventions and any beneficial outcomes.”
While there was some evidence that BFHI may benefit mothers of low educational attainment, the studies compiled and examined by the task force reveal that it is ineffective for mothers overall. Flaherman and Von Kohorn point out that public health officials are currently investing a lot of money and energy into creating system-level interventions; they are encouraged to reconsider their approach on account of these findings.
Flaherman and Von Kohorn also criticize a lack of attention to potential adverse effects of breast-feeding initiatives on infants. They point to rising evidence that common interventions to support breast-feeding can pose risks to infants and lead to complications that are sometimes fatal. These include the ban on pacifiers, which the task force and other recent studies found does not impact initiation or duration of breast-feeding and, moreover, is associated with a reduced risk of sudden infant death syndrome. And there’s the ban on formula, which also does not impact breast-feeding and is sometimes necessary to prevent hyperbilirubinemia (which leads to jaundice), dehydration, and readmission. Other problems with the BFHI include the potential risks associated with enforced skin-to-skin contact and rooming-in (or sleeping in the mother’s hospital room instead of the nursery) when the mother is too sedated or exhausted to properly care for a newborn on her own.
“Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences,” the task force writes in their recommendation statement.
While many, including some of us at Slate, have been questioning the BFHI for awhile now, it is encouraging to see such one-size-fits-all approaches being challenged from on high. Women deserve breast-feeding support that both treats them as individuals dealing with a wide variety of physical and personal circumstances and doesn’t prioritize breast-feeding above all over infant health concerns. I suspect that in many cases the all-in approach promoted by the checklist-friendly, system-level interventions may actually be turning women away from breast-feeding: A tired and vulnerable new mother could easily be led believe that anything short of exclusive breast-feeding for six months makes her a failure, and if she can’t do it, she might as well give up. A potential, and very welcome, secondary effect of a rise in individual interventions would be a rise in individual definitions of breast-feeding success—which just might lead to a rise in breast-feeding overall.