Abstract
Dear Editor:
We are responding to Dr. Arthur Eidelman's editorial, “A Critical Review of the Baby-Friendly Hospital Initiative Is in the Works,” published in the November 13/9 2018 issue of Breastfeeding Medicine, 1 as it downplays the significant impact of the Baby-Friendly Hospital Initiative (BFHI) in improving lactation support and overall breastfeeding rates.
We agree with his assertion that the number of designated hospitals is but one measure of BFHI success and that the attainment of Healthy People (HP) goals for breastfeeding initiation, exclusivity, and duration are also critically important metrics. Baby-Friendly USA (BFUSA) strives to assist our nation in attaining HP goals. Breastfeeding duration can only be achieved if initiation and exclusivity are adequately supported, a key function of the BFHI. According to the Centers for Disease Control and Prevention (CDC), breastfeeding initiation and duration continue to rise and several HP goals have been exceeded. HP MICH-21.1 is to increase the proportion of infants who are ever breastfed to 81.9%. The 2018 CDC breastfeeding report card shows the rate to be 83.2%. 1 This is up from 76.1% in 2009 2 in part due to the implementation of the BFHI for the past 8 years.
For more than 25 years, the BFHI, with the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes as its foundation, has worked to empower families with informed decision-making through the provision of objective, evidence-based information, and care practices that support breastfeeding. The practices interplay with one another that strengthen their impact. Although Dr. Eidelman points to research that evaluates each individual step, there is strong evidence demonstrating the effectiveness of multiple steps combined. 3
Baby-Friendly designation is conferred through an independently conducted external assessment that confirms proper implementation of all Ten Steps by a facility. The BFHI postdesignation accountability activities are vital to retaining the standards.
Although the BFHI standards are rigorous, the U.S. Guidelines and Evaluation Criteria (GEC), which describe the designation requirements, specifically instruct facilities to implement them within an environment that is neither restrictive nor punitive and is sensitive to the culture and needs of families. The GEC support individualized care and responsible clinical decision-making, not inflexibility or rigid adherence to breastfeeding at all cost. Guideline 5.2 of the 2016 GEC specifically states “Additional individualized assistance should be provided to high risk and special needs mothers and to mothers who have breastfeeding problems or must be separated from their infants.” 4 Health care professionals are responsible for making and documenting clinical judgments on a case-by-case basis when a variation from the Baby-Friendly protocol is appropriate.
Recently, the WHO/UNICEF updated its BFHI Guidance and enhanced the 10 steps. BFUSA was involved in this improvement process along with other global breastfeeding support organizations. We value these improvements in our process because of our commitment to providing dyads with optimal care. We are pleased with the ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding. It is extremely comprehensive and a valuable resource. BFUSA has assembled an expert panel to guide the revision process for the United States. a
