The Baby-Friendly Hospital Initiative (BFHI) was launched nearly 30 years ago with an eye toward motivating hospitals and birthing centers to become more supportive of breastfeeding. Since then, more than 6.5 million babies have been born in Baby-Friendly designated facilities in the U.S.

The initiative isn’t new, but it is a growing trend. However, some are cautioning against it.

Lactation support was the goal when the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched Baby-Friendly in 1991. Its key tenet says breastfeeding is the natural biological conclusion to pregnancy and an important mechanism in the natural development of the infant.

The initiative promotes the Ten Steps to Successful Breastfeeding, which includes allowing mom and baby to bond by rooming together around the clock, breastfeeding encouragement, and the training of staff in skills that support breastfeeding.

While it sounds like a win for both mom and baby, Dr. Joel Bass of Newton-Wellesley Hospital says the program does not guarantee breastfeeding success.

Bass, a practicing pediatrician for more than 40 years, was the lead author of an October 2019 paper published in the Journal of Pediatrics that criticized aspects of the initiative, including the assertion that moms in states with many Baby-Friendly hospitals are more likely to start breastfeeding than those in places without.

His study, he said, used data from all 50 states and three territories to compare the success of the Baby-Friendly program on breastfeeding outcomes at 3, 6, and 12 months after hospital discharge.

“Our findings were consistent with other findings: the Baby-Friendly process is discouraging to both the parents and providers,” he said. “The program is complex with lots of requirements and there are a lot of criteria that would be really problematic for a lot of mothers.”

Newton-Wellesley Hospital sees more than 3,700 births per year.

“We’re tremendous breastfeeding advocates,” Bass said. “We are really committed to supporting breastfeeding even though we are not Baby-Friendly. Every one of our mothers sees a lactation specialist while in the hospital.”

The only Baby-Friendly designated birthing site in Central Massachusetts is Saint Vincent Hospital in Worcester, where more than 2,000 families welcomed babies last year.

The hospital’s Center for Women and Infants sought the BFHI designation in 2014 with a goal of offering the best care for infant feeding and mother-baby bonding.

Dr. Michele Sinopoli, OB/GYN department chief at Saint Vincent, says some of the program criticisms stem from misinterpreting the initiate.

“Our approach is truly baby friendly,” she said. “Our faculty have really taken the true meaning of the initiative with the understanding that not one size fits all.”

Lisa Beaudry, director of the center for women and infants at Saint Vincent, agreed.

“A lot of people think Baby-Friendly means babies are pushed on their mom. We support mom’s decision. If that decision is formula feeding, then we support it. What’s unique about St. V’s is we staff a nursery so we can give care centered on mom’s needs,” she said.

In 2007, less than 3 percent of U.S. births occurred in approximately 60 Baby-Friendly designated facilities. By 2019, it rose to more than 28 percent of births in more than 600 facilities across the country, according to BFHI.

Today, more than 20,000 maternity facilities in 150 countries have earned the Baby-Friendly designation.

“Since its inception over two decades ago, we have seen maternity wards transform from places historically infused with enormous influence from formula companies and maternity care and infant feeding practices that undermined breastfeeding, to environments in which evidenced-based care is provided, education is free from commercial interests, and mothers are supported in reaching their infant feeding goals,” says the BFHI website.

The nonprofit Fed Is Best Foundation, comprising volunteer health professionals and parents, studies scientific literature on infant feeding and real-life infant feeding experiences to provide advice and resources for safe infant feeding with breast milk, formula, or a combination of both.

The organization cautions mothers about feeding complications in exclusively breastfed newborns who don’t receive enough breast milk. Those complications include excessive jaundice hypoglycemia, and dehydration, which can threaten a newborn’s brain.

“We have found that mothers often feel immense pressure by society and by current breastfeeding protocols to only breastfeed their newborns, even when they do not have enough milk to do so. Insufficient breast milk production affects at least 1 in 5 women in the first days of an infant’s life,” says Fed Is Best.

Saint Vincent received its BFHI designation in 2019 after a five-year journey that included educating and training the staff to assist in breastfeeding.

Mary Randolph, lactation consultant, said the baby’s pediatrician monitors feeding, daily weight, and stools to decide whether mom is successfully breastfeeding. If not, she said, staff give mom the option of donor milk or formula.

“It’s the pediatrician’s decision,” Randolph said.

Pam Dolan-Smith is the nurse manager for the mother/baby and nursery areas at Saint Vincent.

“Moms who delivered here before the initiative and again after appreciate the amount of care provided in the patient rooms,” she said

The International Code of Marketing Breastmilk Substitutes was adopted by the World Health Assembly in 1981 to promote good infant nutrition through breastfeeding and by ensuring the proper use of breast-milk substitutes when necessary.

The WHO and UNICEF administer the program internationally. Baby-Friendly USA Inc. is the accrediting body and national authority for the initiative in the U.S.

Both organizations agree that “breast is best” for nutrition in the first six months because it offers health benefits to both mom and baby.

“Before the Baby-Friendly Hospital Initiative began…commercial interests significantly influenced infant feeding practices in ways that undermined breastfeeding. Baby-Friendly facilities are centers of support in which evidenced-based care is provided, education is free from commercial interests, all infant feeding options are possible, and individual preferences are respected,” says BFHI.

Bass said his greatest objection to the growing trend toward the BFHI is a U.S. Surgeon General recommendation that all hospitals should pursue the designation.

“My concern is in making it a government-recommended goal for the whole U.S.,” he said. “The government should be encouraging people to breast-feed but to make every hospital in America Baby-Friendly is a terrible mistake.”

Bass’ advice to expectant mothers is to do their homework before selecting a birthing facility because some Baby-Friendly practices, such as rooming together when mom needs rest, could be difficult for some.

“Stress is not compatible with breastfeeding,” he said. “My feeling is that mothers generally have a good sense of what they need to support their babies.”

Other Baby-Friendly hospitals in Massachusetts include Brigham and Women’s Hospital in Boston, Emerson Hospital in Concord, Cambridge Birth Center, Boston Medical Center, Massachusetts General Hospital in Boston, and Holyoke Medical Center.