Is the Baby Friendly Movement Truly Friendly? :

A Closer Look at the “Baby-Friendly Initiative” Effects on the Mother – Infant Dyad

Jasmin Smith, RN

College of Central Florida

 

 

 

 

 

 

Is the Baby Friendly Movement Truly Friendly? : A Closer Look at the “Baby-Friendly Initiative” Effects on the Mother – Infant Dyad

       The “Baby Friendly” movement is a multifaceted initiative organized by the World Health Organization (WHO), aimed at supporting, facilitating, protecting and promoting breastfeeding during the postpartum hospitalization and transition home (Benoit & Semenic, 2014). The goal is getting mothers to exclusively breastfeed for six months, with hopes of continuing this diet for the newborn for up to two years (Wieczorek, Schmied, Dorner, & Dür, 2015).

Purpose

       The purpose of this study is to discover if the Baby Friendly Movement (BFM) can become unfriendly and unholistic towards the mother-infant dyad. Further, barriers to implementing the Baby Friendly Movement (BFM) in North Central Florida will be explored.

Problem

         Since 1991, the World Health Organization has been pushing to mandate the BFM movement throughout hospitals globally (Wieczorek, Schmied, Dorner, & Dür, 2015). While breastfeeding is the uncontested best choice for a newborn, the baby friendly movement pushes breastfeeding as the only choice for the infant, creating tension and anxiety for the mothers when this is unachievable.

Research Question

         Since mothers play a huge role in the wellbeing of the newborn, can mandating the Baby Friendly Movement (BFM) backfire and create an unfriendly environment for the mother- infant dyad in the North Central Florida Area?

 

Significance to Nursing

       This study is significant to nursing, as findings will provide additional material nurses may reference when trying to explore, understand and educate others about the BFM. As nurses we are called to do no harm and provide holistic care to our patients; with the BFM health professionals often lose sight of both sides of the equation. In order to do what is best for the newborn, one must also take into consideration the effect on the mother, as this is a co-dependent dyad. By advocating holistic care and acknowledging both parts of the dyad, nurses can accomplish aspects of the BFM, improve patient satisfaction, and improve breastfeeding rates.

 

Study Theoretical Framework

Ramona Mercer’s theory of “Becoming a Mother” will be the guiding framework for this study. Mercer focused on maternal role attainment and identified that maternal satisfaction/attainment, and thus, successful implementation, was based upon preconceptions and societal influence. For example, there is a common phrase of “breast is best.” A new mom having heard this and being cared for in a Baby Friendly environment may desire to breastfeed due to the social stigma. By initiating Baby Friendly strategies, the nurse would be helping the mother achieve self-approval and help her transition into the role of motherhood. This scenario could also create barriers and cause the mother not wanting to breastfeed to feel pressured, due to giving birth in a Baby Friendly setting. Furthermore, this pressure could result in frustration and the inability to accept oneself as a successful mother.

            Mercer is well known for her contributions to nursing in understanding the process of becoming a mother and the various factors and relationships affecting this milestone. Mercer highly advocated the importance of supporting the mother infant dyad, as its care influenced maternal role attainment (Alligood, 2014). According to Mercer, health includes both the mother and the father’s interpretation of current health, prior health, health concern, sickness orientation etc. It also evaluates the newborn’s health status as established by healthcare workers and the parents’ perceptions. Mercer acknowledges that health status can either positively or negatively influence satisfaction in maternal-child role development (Alligood, 2014). With this in mind, mandating exclusive breastfeeding via the BFI movement, maternal role attainment could be affected in a negative way.

            Mercer’s theory applies to this study as patients delivering in “Baby-Friendly” locations are faced with rules that may alter maternal – role attainment or maternal satisfaction, especially if the mother has difficulty breastfeeding. The main issue with the BFI movement is that it focuses primarily on the newborn and not on the mother- infant dyad as a whole. If this dual relationship/population were approached using Mercer’s framework, there would likely be a rise in quality of care and acceptance of the BFI movement.

Literature Review

           The Baby Friendly Hospital Initiative (BFHI) has been strongly encouraged since the early 1990s when the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) initiated the movement to promote breastfeeding across the globe (Wieczorek, Schmied, Dorner, & Dür, 2015). According to Merewood (2012), “the Baby-Friendly Hospital Initiative thrives as one of the greatest international

health initiatives ever, uniting clinicians, researchers, and advocates around a simple set of guidelines, with the unique purpose of creating healthier human beings from day one”   (p. 271). Although the underlying intent of promoting breastfeeding is understood, there are multiple factors that bring into question this initiative’s “friendliness.”

           Wieczorek, Schmied, Dorner, and Dür (2015) conducted a qualitative study evaluating the barriers hindering the successful implementation of the BFHI in Austria. This study outlined the Ten Steps to Successful Breastfeeding, (Smith, Moore, & Peters, 2012), (Table 1) , and then used an interdisciplinary approach identifying barriers to successful implementation. The research was conducted via interviews and included physicians, quality mangers, midwives, and nurses; however no interviews were conducted on the mothers giving birth in a “Baby Friendly” hospital setting (Wieczorek, Schmied, Dorner, & Dür, 2015).

Table 1

The Ten Steps to Successful Breastfeeding

The Ten Steps to Successful Breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff. 2. Educate all healthcare staff in skills necessary to implement this policy. 3. Inform pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within 1 hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in, allowing mothers and infants to remain together for 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Smith, P. B., Moore, K., & Peters, L. (2012). Implementing Baby-Friendly Practices.     MCN, The American Journal of Maternal/Child Nursing, 37(4), 228-233.   doi:10.1097/NMC.0b013e31825eacfa

            Wieczorek, Schmied, Dorner, and Dür (2015) acknowledged that successful implementation of the BFM would require change and collaboration among health care professionals. The researchers also acknowledged that the BFM contains many sub sets requiring intervention prior to successful BFM achievement. These sub groups include implementing breastfeeding, education on breastfeeding and promoting skin-to-skin contact (Wieczorek, Schmied, Dorner, & Dür, 2015). Despite the overall consensus that this is a noble endeavor they acknowledged that the survey participants identified that the BFM is not in all aspects friendly. One midwife stated, “Baby- Friendly isn’t equal to mother –friendly,” acknowledging that BFM criteria pressures mothers to exclusively breastfeed, and ban pacifiers (Wieczorek, Schmied, Dorner, & Dür, 2015, p. 9).

            In addition to factors affecting the success of achieving the Baby Friendly status, research studies have shown a better success rate when implementation considers both mom and baby (Smith, Moore, & Peters, 2012). Smith, Moore, and Peters (2012), promoted mothers having a choice in whether or not to breastfeed: if the choice was to formula feed, then the mothers should be provided with information showing the benefits of breastfeeding (Smith, Moore, & Peters, 2012). This intervention resulted in achieving a 76% exclusive breastfeeding rate during 2011 at the hospital where their research was conducted. Further, 79% of the mothers surveyed replied that they felt they had learned how to “properly feed their babies” (Smith, Moore, & Peters, 2012, p. 230).

         Nickel, Taylor, Labbok, Weiner, and Williamson (2013) conducted a qualitative study, focused on barriers that have prevented many hospitals achieving Baby Friendly status. They hone in on the implementation’s approach, recognizing that patients are more teachable when they are supported and not forced to implement breastfeeding.

One survey participant, a nurse manager, stated that “I think you have to adjust to the patient’s needs and not force the patient to adjust to our needs – what we are wanting to do” (Nickel, Taylor, Labbok, Weiner, & Williamson, 2013, p. 960).

         Benoit and Semenic (2014), conducted a qualitative study specific to BFM friendliness in the neonatal intensive care unit (NICU) setting and noted that exclusive breastfeeding in these circumstances can often be very stressful to the mother. One quote from the authors was particularly revealing:

     Participants indicated that mothers with infants, in the NICU were often required to pump for long periods of time and that maintaining an adequate milk supply with a mechanical breast pump was difficult and discouraging. The stressful experience of having an infant in the NICU was described as negatively influencing maternal milk production and therefore mothers required long term pumping support, including the use of pharmacologic galagtagogues such as domperidone, to help maintain maternal milk supply (Benoit & Semenic, 2014, p. 618).

   Nickel, Taylor, Labbok, Weiner, and Williamson (2013) noted another barrier identified to successful implementation of the BFHI was that there were too few licensed lactation consultants available to meet exclusive breastfeeding needs. One nurse surveyed stated “even when staff are capable of providing breastfeeding support, patients refuse their assistance; [and] one respondent explained, ‘patients aren’t receptive to you because you don’t have the title ‘Lactation Consultant’ ” (Nickel, Taylor, Labbok, Weiner, & Williamson, 2013, p. 961).

           Healthcare workers play an important role in successfully implementing a friendly baby environment. Some are resistant to implementing the BFM due to gaps in knowledge, skills, and comfort level surrounding such practices (Benoit & Semenic, 2014).

         Grosse (2014) reflected on her recent birth experience when she wrote an article titled “No Nursery, No Formula, No Pacifier.” Grosse (2014) was surprised to find out that although she had a very pleasant birth experience, the care she and her baby received   was not considered “Baby Friendly.” This intrigued her to reach out to other new parents in her community who had given birth in Baby Friendly facilities to see if their experiences differed. She received many positive responses; however, the negative responses were revealing. One young woman who struggled with breastfeeding wrote: “ [I] felt the pressure to breast-feed was pretty overwhelming—even though it was actually something [I] wanted to do. ‘I had a lot of problems breastfeeding and they were bound and determined that no formula would be had if they had any say about it,’ she continued ‘I understand what they were doing but man, that was rough’ ” (Grosse, 2014, paragraph 8).

         As a result of this literature review, the benefits of continuing to support the Baby Friendly Initiative is highly important. However, as the literature also revealed, there are areas deserving of further research, including shifting the focus on the mother-dyad as a whole. This includes limiting pressuring attitudes towards breastfeeding, and replacing them with supportive ones, such as respecting the mother’s choice. Until the focus is shifted to include the mother’s wishes and other identified limitations are reduced and/ or eliminated, success of the BFM will continue to struggle.

Ethical Considerations

Ethical approval will be obtained from an Ethics Committee prior to starting any collection of data. Written disclosure, outlining the content and purpose of the study will be provided to participants by means of an informed consent form (ICF). Confidentiality and autonomy will be maintained, and signed ICFs obtained.

Proposed Qualitative Approach

Semi – structured interviews coupled with thematic analysis will be conducted among willing postpartum mothers. The study will be limited to the first 20 responders meeting the criteria of delivering in the last 3 months, as well as having breastfed their newborn at least once. Participants will be recruited from local North Central Florida hospitals. To promote comfort and familiarity, each interview will be held at the participant’s location of choice, whether that be in their home, or at a public meeting place, and two interviewers will attend each session. Interviews will be short, averaging 1 – 1 ½ hours, unless the participant verbalizes they need more time. Open-ended questions will be posed to the mother, in an effort to gauge if giving birth in a Baby Friendly environment was perceived as a positive or negative experience. Questions may include: “How would you describe your birth experience?” “Would you consider your birthing facility “baby- friendly, and if so/not – why?” “In what ways did your hospital staff support your breastfeeding experience?” “During your hospital stay, did you ever feel pressured into breastfeeding, and if so please elaborate.” “What kind of concerns have you had about yourself and breastfeeding?” Consents for both audio and visual recordings will be obtained and compiled with reoccurring interview themes to identify further areas to research.

Proposed Quantitative Approach

Surveys will be sent out to the North Central Florida area via social media. Questions regarding cultural dynamics, gravida / para status, previous breastfeeding experience, and mothers’ preferred choice for feeding their newborn will be included. Researchers will ask responders to identify themselves as pro-formula, pro- breast, or neutral and also ask if this decision was influenced by their hospital stay. Researchers will divide respondents into classes based on their response to the previous question and further survey in 6 months to identify rates of maternal satisfaction, maternal frustration, and maternal depression, as well as perceived health of newborn, and perceived bond with newborn, and perceived maternal satisfaction; then analyze and compare the findings between the groups.

Conclusion

The breastfeeding hospital initiative (BFHI) movement is geared towards supporting, facilitating, protecting and promoting breastfeeding during the postpartum hospitalization and transition home (Benoit & Semenic, 2014). If structured around Mercer’s theory of Maternal Role Attainment, this BFM may see a rise in implementation as needs of the mother-infant dyad are addressed. Various barriers have been examined about why the WHO is struggling to implement this movement locally and globally.

The effects of not focusing on the mother when pushing this movement have been reviewed. Generally, the movement has positive implications for practice; however, until the focus is shifted to include the mother’s wishes and other identified limitations are reduced and/ or eliminated, success of the BFM will continue to struggle, both in North Central Florida and across the globe.

 

 

 

 

References

Alligood, M. R. (2014). Nursing theorists and their work (8th ed.). St.Louis, MO:              

           Elsevier Mosby.

Benoit, B., & Semenic, S. (2014). Barriers and facilitators to implementing the baby-      

           friendly hospital initiative in neonatal intensive care units. Journal of

           Obstetric, Gynecologic & Neonatal Nursing, 43(5), 614-624. doi:10.1111/1552-

             6909.12479

Grosse, J. (2014, October 9). Baby-friendly hospitals: Promoting breast-feeding at the

           expense of the new mother? Retrieved from

http://www.slate.com/articles/double_x/doublex/2014/10/baby_friendly_hospitals_promoting_breast_feeding_at_the_expense_of_the_new.html

Merewood, A. (2012). WHO/UNICEF's baby-friendly initiative: The big picture.   Journal of Human Lactation, 28(3), 271-271. doi:10.1177/0890334412447788

Nickel, N. C., Taylor, E. C., Labbok, M. H., Weiner, B. J., & Williamson, N. E. (2013). Applying organisation theory to understand barriers and facilitators to the     implementation of baby-friendly: A multisite qualitative study. Midwifery, 29(8), 956-964. doi:10.1016/j.midw.2012.12.001

Smith, P. B., Moore, K., & Peters, L. (2012). Implementing baby-friendly practices.    

           MCN, The American Journal of Maternal/Child Nursing, 37(4), 228-233.   doi:10.1097/NMC.0b013e31825eacfa

Wieczorek, C. C., Schmied, H., Dorner, T. E., & Dür, W. (2015). The bumpy road to implementing the baby-friendly hospital initiative in Austria: A qualitative study. International Breastfeeding Journal, 10(1), 3. doi:10.1186/s13006-015-0030-0