Abstract
Dear Editor:
The article, “ABM Clinical protocol #7: Model Maternity Policy Supportive of Breastfeeding,” is an outstanding and most welcome addition to the promotion, protection, and support of breastfeeding. 1 It is thorough, inclusive, and with parents and newborns at the center. Thank you so much for this valuable resource. The addition of the International Board Certified Lactation Consultant (IBCLC), especially the IBCLC-to-patient staffing ratio from the U.S. Lactation Consultant Association would have been a valuable addition. However, of even more concern is the editorial in the same journal issue as this policy by Dr. Eidelman regarding the negation of the Baby-Friendly Hospital Initiative (BFHI). 2 His discrediting of the BFHI is most distressing, especially since the model policy specifically 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.” Dr. Eidelman relies on two articles that decry the lack of evidence to support the efficacy of the BFHI. Yes, randomized controlled trials may be the gold standard in the evidence hierarchy, but for certain situations such as breastfeeding, they may be unethical to conduct or not necessarily the best statistical paradigm to use to study a normal process. Breastfeeding is not a medical problem. There are more advanced statistical programs out there!
Dr. Hernández-Aguilar (first author of the protocol) wrote a blog describing the process that was used to write this protocol. 3 She explained that a new system of gradation of evidence was used, called the Oxford Center for Evidence-Based Medicine (OCEBM) criteria. She explains that “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.” Perhaps other statistical methods, such as causal inference, which reflect greater levels of nuance, may be more suitable in studying maternity care practices. 4
Childbirth and breastfeeding management have long used interventions that had no shred of evidence as to their safety or efficacy. These practices were rapidly accepted, became routine care, and are still seen in many hospitals today. Dr. Hernández-Aguilar further states, “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).” The evidence is there. This ABM policy has 194 references! We have statistical methodology that in some instances may be more suitable to the study of breastfeeding and lactation. Instead of accusing hospitals that their quest for quality improvement is motivated by marketing as stated in the editorial, perhaps what is needed are not only better statistical platforms but a look at infant, child, and adult health outcomes when breastfeeding is not challenged by antique maternity care practices. What a shame that there seems to be such a disconnect between this scathing editorial and a protocol that appears to be a real step forward in the support of breastfeeding.