Why 'Baby Friendly' Hospitals Are Still Rare

Beth Skwarecki


January 18, 2017

When Alton Memorial Hospital in Illinois began working toward a 10-step breastfeeding designation known as Baby Friendly, one of the hardest things for hospital staff to get used to was step 4: initiating breastfeeding right after birth.

"[The nurses] kept saying, 'I wouldn't want a goopy, gross baby placed on my chest,'" Lori Fassler says. Fassler is a lactation consultant and nurse clinician who handled much of the staff education necessary to earn the designation.

Mothers had the same reaction, she says, if their previous babies had been whisked away and bathed after birth. But what happened next began to change the nurses' minds.

"It was like the literature says: [The babies] calm down faster, they cry less, they warm up faster, the moms are more calm. When all of that really happened, the nurses got on board," Fassler says.

They now hand over the toweled-off baby as a routine practice, and few mothers refuse. It took over 2 years, Fassler says, but now nearly every baby goes skin-to-skin as soon as they're born. Alton was officially named a Baby-Friendly Hospital in August of 2016.

Ohio is one of many states encouraging more hospitals to become Baby Friendly,[1] in turn spurred by the breastfeeding goals in Healthy People 2020, a government initiative to improve the health of the US population. Across the nation, hospitals are seeing more reasons to make the change, and in some cases are now able to obtain special funding to help make it happen. More than 20 years after the initiative began in the United States, a boom in Baby-Friendly Hospitals is finally beginning to happen.

The Baby-Friendly Hospital Initiative has existed worldwide since being launched by the World Health Organization and UNICEF in 1991. In the United States, the initiative has existed since 1994, but in that time only 404 of the country's more than 3000 maternity hospitals have qualified for the designation.[2] What accounts for the glacial pace of adoption? Doubts from patients and hospital staff account for some of it, but hospital staff and administrators told us that the process of changing policies is slow and difficult for many reasons. Geography also plays a role: The greatest numbers of Baby-Friendly Hospitals can be found on the East and West coasts.

"There are places where the culture is a little slower to adopt," says Trish MacEnroe, executive director of Baby-Friendly USA, but "a lot of states are really catching up." California has 84 hospitals with the designation, for example; in contrast, West Virginia is the only state with none.

Snowballing Support

Government interest in Baby-Friendly and other breastfeeding policies has snowballed over the past decade. First, in 2007, the Centers for Disease Control and Prevention (CDC) began asking hospitals about what and how newborns were eating in the Maternity Practices in Infant Nutrition and Care survey.[3] Every 2 years, maternity hospitals in the United States are asked to fill out the survey. The CDC turns their responses into scores for each hospital and issues breastfeeding report cards for each state and for the nation as a whole. The first survey showed that fewer than 2% of babies born in 2007 entered the world via Baby-Friendly Hospitals.[4]

In 2010, the White House Task Force on Childhood Obesity recommended Baby-Friendly practices as part of a push to prevent obesity with breastfeeding. Soon afterward, Healthy People 2020 and the Surgeon General's Call to Action to Support Breastfeeding both emphasized the importance of evidence-based breastfeeding policies.[5] The surgeon general's report recommended that the government "accelerate implementation" of the Baby-Friendly Hospital Initiative.

That year kicked off a frenzy of expansion. The CDC's Best Fed Beginnings initiative, begun in 2011, aimed to help 89 hospitals from areas with low breastfeeding rates achieve Baby-Friendly status. By the end of the program in 2015, 31 of those hospitals had their designation and another 40 were nearly there.[6] MacEnroe told Medscape that in addition to the 377 hospitals certified at the time of the interview (there are now 404), an additional 725 or so were on the pathway toward full designation.

Many states are urging hospitals to take on the Ten Steps to Successful Breastfeeding regardless of whether they apply for Baby-Friendly status. Baby-Friendly is a specific program with a governing body and a schedule of application and maintenance fees. A large hospital pays $4300 for their designation fee, for example. The Texas Ten-Step Program, on the other hand, is a program funded by Texas's Department of State Health Services. It provides phone and email support to hospitals implementing the 10 steps, and charges no fees. A spokesperson for the department wrote in an email that hospitals usually complete the Texas Ten-Step Program faster than they could complete the Baby-Friendly pathway, and are still encouraged to apply for the full Baby-Friendly designation. Of Texas's 270 birthing hospitals, 18 have Baby-Friendly status, 52 are on the Baby-Friendly pathway, and 122 participate in the Texas Ten-Step Program. Other states have similar programs.[7]

"It's a different intensity of program implementation," says Alison Stuebe, MD, of the Division of Maternal-Fetal Medicine at the University of North Carolina, in regard to the state programs. A solid number of how many hospitals nationwide are enrolled in state and privately funded breastfeeding policy programs doesn't exist, but according to the CDC, more than one half of the nation's hospitals had implemented a majority of the 10 steps by 2013.[8]

Avoiding Guilt

As the Baby-Friendly initiative gains momentum, mothers and staff who don't embrace the program's policies can be left feeling like new, unwelcome practices are being forced upon them. Mothers have told the Washington Post[9] and Slate[10] that they felt uncomfortable with the policies.

But Dr Stuebe sees the policies as potentially reducing the guilt that women feel. "We [used to have] these routine practices that meant the mom came in saying, 'I want to breastfeed' and it got screwed up. And then the mom said, 'I'm a bad mom; I couldn't breastfeed; I must have done something wrong,' when in fact the hospitals were rigged, as it were, to make [breastfeeding] more difficult than it needed to be." She points to a study published in Pediatrics in 2012 reporting that women were twice as likely to meet their personal goals for how long they would like to breastfeed if their hospital used Baby-Friendly practices, including limiting formula feeding.[11]

When Jersey Shore University Medical Center was working on its Baby-Friendly designation, it addressed the guilt issue head-on by adding questions on its patient satisfaction survey asking whether mothers felt "guilty" or "not supported" in their feeding choices. None answered that they felt guilty, according to a report that the hospital published in the Journal of Human Lactation.[12] Baby-Friendly USA lists increased patient satisfaction as a benefit of Baby-Friendly status, and anecdotally many of the hospital staff we spoke to volunteered that patients were happy with the policies once they understood why they were in place.

That's why it's so important for providers to educate patients about breastfeeding long before they show up to the hospital, MacEnroe says. Getting that balance right—offering breastfeeding-centric practices as the default, without inciting guilt or frustration—requires careful education not just for the patient, but also for staff. Nurses in maternity units receive 20 hours of training, including 5 hours of supervised clinical experience. They learn about how lactation works and the rationale behind the 10 steps, and how to assist a mother who is having trouble breastfeeding. They also learn how to discuss formula feeding so that a mother who wants to formula-feed knows how to prepare and give the formula safely. Other providers get a shorter, 3-hour training.

Rhonda Sullivan, a nurse and lactation consultant at Kishwaukee Medical Center in DeKalb, Illinois, said that staff felt torn at first between allowing mothers to make decisions freely and achieving outcomes that would look good on their Baby-Friendly assessments. For most of the 10 steps, designation requires that 80% of mothers report that their care was in line with recommendations.[13]

But if a mother decides that she wants to feed her baby formula, that won't necessarily hurt the hospital's numbers if the staff can document that they discussed her reasons for wanting to formula-feed and made sure that she was aware of the risks and benefits of each of her options.

"The hardest part was getting the team to recognize that when moms are given education and the background to make an educated decision, that's what the whole goal is," Sullivan says.

Hospitals are also addressing patient education by distributing information before women show up at the hospital.

"At that point, it's basically too late," says Deborah McDonald, women's health program director at Allegheny Health Network in Pittsburgh, Pennsylvania. Her hospital distributes a handbook on breastfeeding to patients at affiliated obstetricians' practices, so that women can digest the information little by little during their pregnancies.

Logistical Challenges

Even with all of this support, progress is slow. At Kishwaukee Hospital, Sullivan noticed that policies tend to have a domino effect beyond the obvious. For example, step 1 required changes to policies about how to handle newborns with hypoglycemia. Policies that called for a baby to spend time in a warmer also needed to change to meet goals for skin-to-skin initiation after birth. The hospital's team researched how warmers compared with warming babies through contact with their mothers, and found that the warmers weren't always necessary. "Some practices changed for the better and became more evidence based," she says.

Some hospitals find the entire transition easier than others. Sullivan said that Kishwaukee Hospital had a comparatively easy time in earning the Baby-Friendly designation because it is a small hospital where labor, delivery, recovery, and postpartum care occur in one unit, and because mothers were already rooming in with their babies even before the push toward Baby-Friendly.

By contrast, the University of Pittsburgh Medical Center has seven maternity care facilities, ranging from a few hundred deliveries per year at smaller hospitals up to 9000 at Magee-Womens Hospital. Part of the reason why Magee isn't yet designated as Baby-Friendly is because the hospitals are working to implement one step at a time throughout the entire hospital system rather than certifying hospitals independently of each other, says Jeff Hodges, vice president of patient care services at Magee.

Part of the difficulty, he says, is that training is a massive and expensive undertaking. Staff need to learn about breastfeeding on top of other types of training they already undergo, and that training extends to all areas of the hospital, not just the maternity units. If a pharmacist ends up talking to a new mom, for example, "we wouldn't want them saying something that's counterproductive to breastfeeding," he says.

McDonald agrees that broad changes are both important and difficult.

"Just because it's a slower process doesn't mean that it's unsupported," she says. "We're trying to do it right so it sticks, not just get through because it's the flavor of the month. It's a lifetime change."


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