More Philly Hospitals Are Becoming “Baby-Friendly.” Maybe That’s Not a Good Thing.

The rigid, confounding, densely bureaucratic Baby-Friendly Hospital Initiative has morphed into a system that diminishes a mother’s ability to make the best choices for her child.

baby-friendly hospitals

Five of Philly’s six city birthing hospitals are certified Baby-Friendly hospitals. Photograph by Michael Persico

Less than 12 hours after Benny enters the world, she’s rolled into my room in a plastic bassinet.

I can tell she’s on her way by the soft sound of the wheels coming closer to me. It’s dark except for the dim light of a few monitors, and as I wake up, I survey her from my narrow hospital bed. I recognize her face now — it’s sweet and round, with a tiny pointed chin and a pink mark on her left eye where she was accidentally poked with some instrument in an attempt to coax her into the world. After more than two hours of pushing and my doctor’s skillful attempts to dislodge her, I ended up in surgery. It wasn’t the way I wanted it to happen, but the goal was to get her here healthy.

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I marvel at this face for a minute, and then I unwrap her swaddle and start to feed her. Or try to feed her. It’s so hard. My milk hasn’t come in yet (that usually happens on day three or four and can take longer for women who deliver via cesarean), and though the colostrum that’s there is baby superfood, delivering it to her proves much more challenging than the books and YouTube videos and parenting classes made it seem. But we try, together, for the next 45 minutes. When she’s finished, or maybe just exhausted, I pat her back and smell her head and kiss her face. And then I ring a magic call button; minutes later, a young nurse appears and rolls Benny back down the hall to the nursery, where her diaper will be changed and she’ll be swaddled and put back to sleep. In that short time, I’ve already fallen asleep, and in three more hours, the whole process starts up again.

Nearly four years later, I have my second daughter at the same hospital: NewYork–Presbyterian, on the Upper East Side of Manhattan. The experience is the same, except that I’m older and exponentially more exhausted from already being a mom. All the more reason to appreciate the postpartum care: the kindness, the sense of peace I feel knowing my baby is asleep in the nursery, wrapped like a burrito, while I recover from my second cesarean. And this time around, I’m more adept at breast-feeding.

When it comes time to have my third baby, we’ve moved to Philadelphia, and a friend has recommended her obstetrician at the Hospital of the University of Pennsylvania. I’m anxious about having a baby in Philly. Most hospitals here are “Baby-Friendly” — a term that, up to this point, I’ve only associated with bars that tolerate kids. I’ve been told these hospitals push breast-feeding hard and encourage that practice via “rooming-in,” which means your baby never leaves your side. Unsure how those two concepts relate to each other but very sure I’ll have a third cesarean, I have visions of navigating the nighttime hours exhausted, sore and alone. My anxiety manifests in a series of awkward questions I pose to each doctor I see at my regular appointments: Why is rooming-in necessary? What’s the goal? Do I have to do it? I hear an array of answers … and non-answers. One doctor explains her theory: If you’re on the fence and your baby is sleeping next to you, you’re more likely to try breast-feeding.

Overall, I have a positive experience at HUP. My doctor is top-notch, the nurses are capable and well-intentioned, and Sloane, just like her sisters, is a little slice of heaven. There are differences, though. While there was no question my babies could sleep in the nursery at Presbyterian, here, I have to explain my circumstances to each new caregiver: At age 38 (which, it’s worth noting, classifies mine as a “geriatric pregnancy”), I’ve just had my third cesarean and can barely pick up the baby, let alone transfer her from the bassinet to the hospital bed by myself. My “support person,” who is my husband, can’t be with me because he’s home caring for our other two girls. And because of my physical limitations and the painkillers, I prefer not to room-in with Sloane. I want her to sleep in the nursery so I can squeeze in some rest and have her brought to me when she’s hungry so I can feed her. There are times when I feel as though the nurses are doing me a huge favor by taking the baby, which elicits shame and guilt — feelings I never experienced in the first two go-rounds. And only after I repeatedly speak up do I get the outcome I want.

The push to room-in with baby is part of the Baby-Friendly Hospital Initiative, a set of global standards created by the World Health Organization and UNICEF as a way to promote breast-feeding from birth. Why was it necessary? Well, unless you’re new around here, you know that pretty much every scientist and doctor around the world agrees that breast milk is the healthiest form of nutrition for baby. The list of benefits is miles long, but to give you the highlights reel: Studies indicate that breast-fed babies could have higher IQs, lower rates of asthma, a lower risk of SIDS and childhood obesity, and fewer ear infections. Breast milk is an elixir that can benefit every baby, whether that little bundle is born in Sudan or Society Hill. A breast-fed population is healthier, stronger, smarter — and thus less costly overall.

Though the initiative has been in existence for nearly 30 years, hospitals in Philadelphia have just recently embraced it on a large scale. Institutions that comply with the standards can be certified as “Baby-Friendly,” which is exactly what HUP, Pennsylvania Hospital, Jefferson, Temple and Einstein — five of the six city birthing hospitals — have done. Dozens more in the region — Bryn Mawr, Paoli, Phoenixville, Doylestown — participate in a similar initiative, the “Keystone 10,” run by the Pennsylvania Department of Health.

In order to obtain and maintain the Baby-Friendly certification, facilities have to adhere to the “Ten Steps to Successful Breast-Feeding,” all of which support exclusive breast-feeding. “Do not provide breastfed newborns any food or fluids other than breastmilk, unless medically indicated” is one of the tenets discouraging formula. Pacifiers are looked down upon, too, because they can mask a baby’s feeding cues. And then there’s the rule that insists hospitals enable mothers and babies to remain together 24 hours a day. (Christiana Hospital in Newark, Delaware, doesn’t even have a nursery anymore.)

In theory, the initiative is a noble one: Educate new mothers, provide support, do everything possible to ensure more babies are breast-fed. However, as I learned — and as many women I spoke to for this story experienced — this laser focus on a single target can mean that hospitals lose sight of the individual needs of both of their patients — babies and moms. What’s more, the rigid, confounding, densely bureaucratic Baby-Friendly Hospital Initiative in this country has morphed into something I’m sure was never intended: a system that diminishes a mother’s ability to make the best choices for her child.

A block from Washington Square, in Pennsylvania Hospital’s brick Garfield Duncan building, I enter Solutions for Women boutique, a world where “Breast Is Best.” This in-hospital shop has everything a breast-feeding mom might need — women can be fitted for a new nursing bra, buy an ergonomic breast-feeding pillow, or meet with a lactation consultant. I connect with Debi Ferrarello, a nurse who’s the program director for women’s health and director of parent education and lactation at Pennsylvania Hospital. She’s been on staff for 12 years and has been an integral player in Pennsy’s changeover from traditional birthing hospital to Baby-Friendly-certified. A slight woman with cropped auburn hair and a calming presence, Ferrarello is passionate about the program. We sit together on plastic seats usually occupied by exhausted moms who come here for the weekly support group, and she exalts the benefits of breast-feeding and Pennsylvania Hospital’s part in making it easier for women to succeed at it.

“Even though it’s out there — breast-feed, breast-feed, breast-feed — the forces in society really make it difficult,” Ferrarello tells me. This hits home. I breast-fed three daughters for between nine and 12 months each, and in the seven years since I gave birth to our first, I’ve seen positive changes: more nursing facilities, more support groups, more social media campaigns to #normalizebreastfeeding, more celebs posting brelfies (nursing selfies, for the uninitiated). But, as I lamented every time I found myself perched on the toilet of a public restroom with a hand pump, there’s room for improvement. And in wanting to provide more support for breast-feeding women, the hospital went after the Baby-Friendly certification, achieving the goal in 2015.

Cultural norms for nursing — in this country, mostly, but also beyond — have swung back and forth over the past century. In the 1940s and ’50s, due to innovations and zealous marketing, formula use grew. Then, in the ’70s, pro-breastfeeding group La Leche League rose to prominence and helped spur a movement. Eventually the health-care industry began to reexamine the merits of breast milk in earnest, and studies indicated that all newborns could benefit from it, especially those in less-developed countries where infant mortality was high and access to clean water (which was needed to mix with formula) could be challenging. All of this prompted the World Health Organization and UNICEF to set their sights on increasing the percentage of breast-fed babies worldwide. A huge part of the effort involved creating clear, definitive guidelines that could become standard for every hospital and birthing facility. That’s how, in 1991, the Baby-Friendly Hospital Initiative and its “Ten Steps to Successful Breast-Feeding” was born.

In 2011, after studies linked breast milk with lower obesity rates in children (fighting obesity was a cause championed by First Lady Michelle Obama), Surgeon General Regina Benjamin unveiled her “Call to Action to Support Breast-Feeding.” The document called for increasing education for fathers, generating public-awareness campaigns, increasing the number and diversity of board-certified lactation consultants, and accelerating the “implementation of the Baby-Friendly Hospital Initiative.” (The report also stressed the need to “work toward establishing paid maternity leave for all employed mothers”; clearly, some guidelines gained more traction than others.)

That proclamation gave a boost to some non-government organizations that help hospitals and maternity facilities implement and adhere to those 10 breast-feeding commandments. Baby-Friendly USA, which launched in 1997 and accredited HUP, is one such organization. It charges about $12,000 for the initial designation and more for the subsequent assessments; all travel expenses for BFUSA assessors must be paid by the hospital, too.

The movement is growing. There were 572 Baby-Friendly-designated facilities across the country as of press time, up from 60 in 2007, according to BFUSA. Since HUP became Baby-Friendly-certified, rates of women who breast-feed exclusively (meaning no formula or bottles) have gone up. In 2012, 20 percent of female patients discharged from the hospital after birth were exclusively nursing; now, that number is 63 percent.

Soon after Sarah (the names of all the mothers in this story have been changed to protect their privacy) gave birth in 2014, her wife and her mother were struck with a serious case of food poisoning. At the same time, her father was recovering from major surgery, and her sister was back at Sarah’s South Philly home, caring for her other child. “It devolved into the desert-island scenario,” says Sarah, who was left alone in her hospital suite to care for her newborn. Sarah, who happens to be a doctor, recalls the rotation she did in Pennsy’s maternity ward as part of her training more than a decade ago. That was pre-Baby-Friendly-certification. “It was such a pleasant experience,” she says. “We’d go around and bring the babies out to the moms.” But her own baby at the same hospital? “I was begging the nurses to take her.”

Because Sarah wound up having an emergency C-section and none of her family members were present, she says, the nurses took pity on her and would wheel the baby to their station — which is against hospital policy — so Sarah could get stretches of sleep. They’d wheel her back to breast-feed. When Sarah had the couple’s third baby in 2017, it was a planned cesarean, everyone was healthy, and her wife was there to help: “It was routine, and it was a wonderful experience. Baby-Friendly works great when everything goes well.”

According to Ferrarello, Pennsy and HUP encourage all soon-to-be-moms to bring along a support person to stay with them so they’ll have help lifting the baby and changing diapers: “It could be their partner, their mother, their sister, their friend. All of our rooms accommodate that, because we know it’s really hard.” But there’s a fundamental problem with this: It transfers the burden of responsibility from the hospital to the mother, who has to supply her own help.

This can be challenging. Some women simply don’t have a dedicated support person. Other women, perhaps in strained financial situations, have partners who can’t afford to take off work or have other children to tend. What’s more, formula could be a better option, because some circumstances make breast-feeding nearly impossible — for instance, not having any maternity leave, or doing shift work in retail or food service, where breaks aren’t long enough to pump. Mothers with higher socioeconomic status face far fewer barriers to long-term breast-feeding than lower-income moms.

The support-person request is also singular: I can’t think of another situation in which a patient who has to recover in a hospital is asked to provide her own caretaker. And in the case of a birth, there are two patients to care for: mom and baby. The system has whiffs of sexism. When a friend’s husband had a routine vasectomy, he left with strict instructions from his doctor — plus a pamphlet to show his dubious wife — that he was supposed to put his feet up and rest for a few days. My cesareans were several degrees more invasive, which my husband can attest to after catching a view of my intestines casually sitting in a bowl next to the operating table. And even when birth doesn’t call for an operating room, a human being has still passed through a body. It’s physical trauma that requires weeks of healing. Pennsy isn’t the only hospital that encourages women to supply their own support systems. Some nearly demand it. My sister-in-law gave birth at Christiana, a Baby-Friendly hospital in Delaware, and says she was told it was “a must.” David Paul, Christiana’s chair of pediatrics, told me this isn’t an official hospital policy, but noted that it’s “a lot easier if you have someone in the room with you. All of our rooms have a second bed for a partner.”

The pressures on women physically and emotionally, coupled with practices such as no pacifiers, no formula, no breaks, can strip them of their independence. “I felt like I lost any autonomy,” says one mom.

Tracy, a Washington Square West woman, gave birth to her first baby at Thomas Jefferson University Hospital in 2012 and her second at the same hospital in 2017. In the interim, Jefferson was designated Baby-Friendly. The difference, Tracy says, was stark. She remembers crying in the middle of the night. “I didn’t feel supported. The focus was on you need to nurse, you need to pump, you need to get your milk in,” she says. “I wanted a nurse to come in and take care of me, too.” Cari, a Fairmount-based mother of two, was so happy with the care she got at Jefferson when her first child was born in 2013 that she wrote a letter to the hospital lauding the experience. Just four years later, when her second child was born, she says she was told that the nursery was only available for sick babies (Jefferson says the nursery is open for all babies when needed), and pacifiers were discouraged. “The nurse said, ‘Oh no, we don’t do pacifiers anymore,’” Cari recalls. “‘We’re a Baby-Friendly hospital.’ To be honest, just the implication bothered me. The phrase ‘Baby-Friendly hospital’ — what were you before, baby-unfriendly? It also implies mom-unfriendly.”

The pressures on women physically and emotionally, coupled with practices such as no pacifiers, no formula, no breaks, can strip them of their independence. When Cari delivered her second child, “I felt like I lost any autonomy,” she says. “I felt my own preferences, like giving my own baby a binky, weren’t considered. It just feels like a one-size-fits-all policy.”

For a hospital to achieve accreditation from Baby-Friendly USA, it must adhere to the 10 tenets and strive to meet certain goals. The org wants at least 80 percent of breast-feeding women who are able (i.e., who don’t have a justifiable reason not to, such as they’re recovering from a C-section and on painkillers) to room-in with their babies 23 out of 24 hours a day and eschew formula and pacifiers. Jessica Lazzeri, the clinical director of women’s health nursing at HUP and a key player in the hospital’s changeover, told me that HUP nurses are trained to be flexible and attend to each patient’s needs and that management doesn’t push goals or statistics on the staff. (She also notes that if a woman chooses to formula-feed her baby, she’s given bedside instructions on how to mix and store it — education that didn’t exist before the Baby-Friendly Hospital Initiative.) But cases of sending babies to the nursery or supplementing with formula have to be documented and shared with BFUSA. And if a hospital doesn’t adhere to the standards, it gets dinged and is expected to retrain staff. Nurses I spoke to at a variety of hospitals know that and admit to feeling pressured.

In early February, I met with two postpartum nurses who work for Main Line Health. (They asked to remain anonymous for fear of getting fired.) They believe in the importance of breast-feeding and take the role they play in a mother’s success at it seriously. But as we sat around my kitchen table, they told me that the reason behind the transition to Keystone 10 — the Baby-Friendly initiative from the Pennsylvania Department of Health — wasn’t explained to the team. “The nursery just has a bunch of empty bassinets in it,” one said. “There’s no one staffed down there.” They say that the changeover still causes tension among the staff: Night-shift nurses want to acquiesce to requests from moms who long to get some sleep, but they have to answer to day-shift colleagues demanding to know the next morning why mom didn’t room-in. “It’s a constant back-and-forth,” said one nurse. “They don’t see these moms at night. I want everyone to come in at three in the morning when these moms are having mental breakdowns.” Barbara Wadsworth, senior vice president of patient services and the chief nursing officer of Main Line Health, denies the nursery was ever unstaffed but says nurses may have perceived it was for a “short period of time” while the organization was trying to promote rooming-in, and that this has been addressed and changed. She also says the hospital’s postpartum nurses are all given 20 hours of training on breast-feeding and the Keystone 10 initiative.

baby friendly hospitals

Photograph by Michael Persico

Kathleen Sibre, nurse manager for Jefferson’s Maternal-Infant Unit, says there were complaints after Jeff launched the initiative: “When we first did it, there were some moms who were upset who had had babies before. But if we talked with them and explained what we were doing, they were okay.” HUP’s Jessica Lazzeri notes that moms who deliver at HUP and Pennsy give their experiences high marks on discharge surveys, which management reviews regularly. But Ferrarello admits that not all patients are happy with the BFHI changes.

According to Sibre, Jefferson went after Baby-Friendly accreditation for the same reason HUP did: to improve the care and education provided to patients by standardizing processes that had already been in place for years, and to increase the percentage of moms who breast-feed exclusively. Sibre says nurses are trained to work with each patient to achieve these goals but can also step in if a mom is, in her words, at her “breaking point”: “There are times when patients may need that bit of a break. We aren’t saying four or five hours — just an hour, if the mom needs that rest. But we are going to take that baby back in an hour.” She estimates that 95 percent of mothers at Jefferson stay with their babies 24/7.

Trish MacEnroe, CEO of Baby-Friendly USA, acknowledges that some women are unhappy and says BFUSA is attempting to address their concerns. “We feel pretty strongly that there’s misinformation about the Baby-Friendly Hospital Initiative — that people think we force women to breast-feed,” she tells me over the phone, hours before she’s off to Geneva to meet with the World Health Organization. “Nothing could be further from the truth. We just want parents to have unbiased and evidence-based information and empower them to make a decision.”

By the end of our conversation, though, MacEnroe has explained that if I were to choose to sleep alone, with my baby snoozing away in the nearby nursery, I would get an intervention: “We would want the facility to talk to you about that.” As a person who gave birth to three kids and chose to breast-feed exclusively each time, I find it hard to reconcile how this initiative empowers a woman even as it discounts her choices so routinely.

Nurses are required to push back in a way that salespeople refer to as “objection handling.” Step seven of the BFUSA guidelines recommends that they: “Allow mothers and infants to remain together 24 hours a day. … When a mother requests an infant be cared for in the nursery, the health care staff should explore the reasons for the request and should encourage and educate the mother about the advantages of having her infant stay with her in the same room 24 hours a day. If the mother still requests that the infant be cared for in the nursery, the process and informed decision should be documented. In addition, the medical and nursing staff should conduct procedures at the mother’s bedside whenever possible.”

In 2019, the language has a distinct echo of The Handmaid’s Tale.

Christie del Castillo-Hegyi is an affable 43-year-old with an impressive résumé. Based in Arkansas, she’s an ER doctor and a former National Institutes of Health scientist who got her undergraduate degree at Brown University, where she studied brain injuries. She’s also a mother of three. In March of 2015, she published an open letter detailing the heartbreaking story of her first child’s birth in Albuquerque. Her newborn had jaundice, hypoglycemia, and severe dehydration after having suffered accidental starvation in the early days of exclusive breast-feeding. She wrote about the misinformed breast-feeding advice she got from hospital staff and how her child, now nine, lives with long-term developmental disabilities and seizures as a result of the starvation. “We are potentially putting ourselves at odds with the protective natural instinct to respond to a baby’s cry by telling mothers that their colostrum is enough (which for many it may not be) and by making them fear failure by giving their child supplementation when they need it,” the letter declares. She says the Baby-Friendly Hospital Initiative’s exclusive breast-feeding guidelines are dangerous.

A year after she wrote that letter, del Castillo-Hegyi and Jody Segrave-Daly, a lactation consultant and NICU nurse, launched Fed Is Best, a nonprofit that promotes safe infant feeding and serves as a resource for parents who breast-feed, bottle-feed or both. It’s one of the first organizations to publicly question the breast-feeding-only policies adopted by hospitals and proselytized by Baby-Friendly USA.

The volunteer-run foundation has more than 700,000 Facebook fans, including maternity nurses, doctors, and scores of women looking for support from a community that doesn’t stigmatize formula or bottles.

Fed Is Best has published hundreds of stories from mothers sharing everything from feelings of shame and guilt to dangerous complications and, in at least one case, infant death. Jillian Johnson delivered her son Landon in a Baby-Friendly hospital in Southern California that allegedly only provided formula with a prescription. Committed to breast-feeding, she fed Landon round the clock. A hospital lactation consultant told her that because of her diagnosis of polycystic ovarian syndrome, she might be producing inadequate milk and suggested she take herbs to boost her supply. Less than 12 hours after the baby came home, he went into cardiac arrest from dehydration; he died 15 days later. “If I had given him just one bottle, he would still be alive,” Johnson wrote.

A few days after Benny, our oldest child, was born, her bilirubin levels were still rising. I was told there were two causes: a blood-type incompatibility issue, and the fact that because of the cesarean, my milk hadn’t come in yet. (Milk helps flush out the bilirubin.) Nurses at Presbyterian encouraged me to supplement with formula, even providing me with a tube system to mimic breast-feeding. I never entertained the idea. Looking back on that fraught time now — we had to return to the hospital less than a day after being discharged because Benny’s bilirubin level was dangerously close to passing the “blood-brain barrier” — I can’t believe I didn’t just give her the goddamn formula. Our baby recovered, thanks to treatment with specialized lights and the frenzy of pumping I did to eke out one ounce of milk each hour. When I read the Fed Is Best stories, even seven years later, I feel a fresh wave of relief — but also have a sharp realization. Nowadays, mothers are judged for all kinds of choices we make for our babies, especially how we feed them. The pressure I felt to breast-feed — from other moms, medical professionals, society at large — was rooted long before I actually became a mom.

The 2011 Surgeon General’s “Call to Action” kicked off a flurry of breast-feeding initiatives nationwide. According to del Castillo-Hegyi, Baby-Friendly USA has had a hand in guiding the narrative when it comes to implementing best practices. The problem, she says, is that the organization has a clear self-interest in the outcome — accreditation is Baby-Friendly USA’s entire raison d’être, and the fees that hospitals pay to be designated Baby-Friendly are part of what keeps Baby-Friendly USA solvent. “Whatever organization is involved with something as important as infant health and infant feeding and things that can literally change the course of an infant’s life should not have financial conflict of interest.”

In 2016, around the time Fed Is Best was launched, Joel Bass and Tina Gartley, pediatricians at Newton-Wellesley Hospital in Massachusetts, and Ronald Kleinman, a physician from the department of pediatrics at Massachusetts General Hospital, published a paper in the Journal of the American Medical Association titled, “Unintended Consequences of Current Breast-Feeding Initiatives.” In it, the doctors outlined the dangers of the BFHI — specifically, the risks of suffocation and falls for babies whose mothers fall asleep while holding them. The paper acknowledges that exclusive breast-feeding and rooming-in have benefits in the postpartum period but notes that especially for women who are exhausted from long birthing experiences or are on medication post-cesarean, there are also risks: “An overly rigid insistence on these steps in order to comply with Baby-Friendly Hospital Initiative criteria may inadvertently result in a potentially exhausted or sedated postpartum mother being persuaded to feed her infant while she is in bed overnight, when she is not physically able to do so safely.”

In fact, medical professionals are increasingly identifying newborn falls as a safety risk, and some experts are pointing to policy changes like rooming-in as the possible culprit. A December 2018 article in Pediatrics (the official journal of the American Academy of Pediatrics) concludes, “The majority of in-hospital neonatal falls are associated with caregiver fatigue. Common efforts to promote breast-feeding, such as rooming-in practices, may contribute to fatigue and increase the risk of falls during hospitalization.” In many hospitals, patients must sign a document saying they won’t co-sleep with their infants, but it happens anyway. One OB resident who did a brief stint at Jefferson told me she’d often entered patient rooms during her early-morning rounds to find moms asleep with their babies. Sarah, the physician who delivered at Pennsy, admits she fell asleep with her newborn son in her arms because she was too sleepy to put him back in his bassinet. Add painkillers into the equation, and it’s not hard to understand how women fall asleep in the middle of nursing or are too weak to return their babies to the bassinet. You’re prohibited from driving or operating heavy machinery while under the influence of opioids, so it doesn’t make much sense that one would be allowed, let alone encouraged, to handle a seven-pound infant with a soft skull at 3 a.m., all alone.

Joel Bass — who is also a professor of pediatrics at Harvard Medical School — strongly believes in the virtues of breast-feeding, including its protective values against SIDS. In the past several years, though, he’s been one of the most vocal challengers of the way breast-feeding policies and initiatives have been implemented in the United States. “It seems to have lost its rational grounding,” he told me over the phone in February. “People say that if you’re against the designation, you’re against breast-feeding, and there’s not a shred of truth to that.”

In late 2018, the World Health Organization and UNICEF updated their terms and recommendations for the Baby-Friendly Hospital Initiative. When it comes to pacifier use for full-term infants, the organization now recommends “counseling mothers on their use, rather than completely prohibiting them.” The new guidelines also place less emphasis on Baby-Friendly designation, stating, “While designation is one option that countries can consider to encourage change in facilities providing maternity and newborn services, it is only one of a number of useful options to consider.”

Baby-Friendly USA has acknowledged but not officially effectuated these updates, although MacEnroe says there will be changes for 2020. She says it’s been “a pretty tough debate with [WHO] on that topic” but maintains that the designation is still crucial: “Our perspective is that it is really more about the 10 steps; however, it is the accountability of the accreditation that ensures that the 10-step practices remain in place.”

Locally, some institutions are breaking with protocol. In early May, when I check in with one of the Main Line Health maternity nurses I spoke with last winter, she says issues were addressed, and now they are “allowed to have a nursery” from 11 p.m. to six a.m. (“When we tell the moms we are able to take their baby at night, they say, ‘Phew, I heard you didn’t anymore,’” she says.)

“My own feeling,” says Bass, “is that the public-health agencies … should align themselves with the new WHO guidelines, focus on the new evidence, focus on letting institutions and towns and geographic areas do what’s right to enhance breast-feeding that works for them.” While the Newton-Wellesley hospital where Bass practices isn’t designated Baby-Friendly, for example, nursing moms see a lactation consultant daily during birth hospitalization, and the facility runs an outpatient lactation clinic and offers free weekly breast-feeding peer support groups. The hospital’s rates of women initiating breast-feeding are consistently over 90 percent. This seems to make sense. A one-size-fits-all approach — with strict policies and tracked statistics — to something that varies endlessly leaves no room for patient-focused care. Women’s health, circumstances, support systems in the hospital and once they return home, and amount of maternity leave, not to mention when and where and how their babies decide to enter the world, aren’t all the same. The World Health Organization’s updates point to a return to a commonsense perspective.

Meanwhile, as the government hammers out its latest Healthy People goals — the set of science-based objectives released every decade and aimed at improving Americans’ health — Fed Is Best is making sure its voice is being heard. The nonprofit has made recommendations to the Department of Health & Human Services in hopes of implementing changes in how institutions message their breast-feeding initiatives. It claims that the BFHI’s focus on exclusive breast-feeding results in hundreds of thousands of cases of insufficient-feeding complications each year and says metrics are set and pushed “despite the lack of evidence from randomized, controlled trials.”

But even if hospitals ditch accreditation, it could be hard to pivot back. The semantics alone make it difficult. What hospital would want to announce, “We are no longer Baby-Friendly”? Sorry, babies.

Published as “Does Mother Know Best?” in the July 2019 issue of Philadelphia magazine.