Let’s Talk about Clinical Standards and Clinical Judgment

Welcome to World Breastfeeding Week!

As I write this, there are 576 Baby-Friendly designated facilities in this country. This seemed unattainable when I joined Baby-Friendly USA (BFUSA) almost ten years ago. In a few short years, we have seen massive change in an industry that is typically slow to shift its deeply-embedded and commercially-influenced practices.

We have achieved a significant and important cultural shift because, as a global public health initiative, the Baby-Friendly Hospital Initiative (BFHI) promotes evidence-based best practice standards that increase breastfeeding rates and advance the wellbeing of mothers and babies across the population. It gives me great pride to know that Baby-Friendly practices are now standard practice in maternity units across the country, even for many facilities that are not officially Baby-Friendly designated.

At the same time, however, I know that there is a flipside to this coin. While the widespread adoption of the standards has established consistency and predictability of practice across the country, I also wish to remind everyone that Baby-Friendly protocols are not the only way to practice under all circumstances. It is imperative that clinical judgment also be exercised.

Baby-Friendly guidelines are just that – guidelines – and should be followed in most circumstances.  However, there are times when rigid adherence to these protocols is not the best thing. We depend on the wonderful, talented, compassionate caregivers at Baby-Friendly designated facilities to know when to individualize care for the mother or infant based on the circumstances that present themselves in each unique situation.

A good example is with rooming-in. Recently, BFUSA has received some feedback from mothers who had negative experiences with rooming-in in their birth facility. These mothers describe being unable to care for their infants shortly after birth due to some combination of extreme exhaustion, pain and medications and not having a family member or friend with them for support. Their experience was one of feeling unduly pressured to keep the baby in the room and shamed by their healthcare providers when they asked to have the infant removed from the room for a while. Some mothers report this dynamic actually undermined their desire and intent to breastfeed, which of course is the exact opposite of our intent.

Clearly, this should not happen.

Rooming-in is one of the Ten Steps to Successful Breastfeeding, and therefore part of the BFHI, because strong scientific evidence has shown it facilitates mother-baby bonding and breastfeeding initiation. The goal is to empower parents to learn about their baby’s needs and cues so they may confidently care for him/her when they get home.

However, this does not mean it is the right thing to do for all mothers in all situations – and the Baby-Friendly guidelines make this very clear. The guidelines state that rooming-in should be the standard approach unless there are “documented justifiable reasons for separation.”

If a mother feels unable to care for her baby after her birth and requests time apart, giving her a respite may help her regroup. Her provider should engage her in a collaborative conversation to ensure she understands the reasons for the rooming-in policy, gently work with her to see if there are ways that they can support her to room-in, but if not, document her informed decision, and then respect the request without making the mother feel any guilt or shame. The BFHI is about educating, supporting and empowering mothers, not shaming them.

And it’s worth noting that facilities will not get “dinged” (as some media stories have reported) in cases where care deviates from the standard if the deviation is for justifiable reasons and those reasons are properly documented.

Rooming-in is the standard of care and the right policy for the vast majority of cases – and most mothers love it and feel it enhances their postnatal experience. We ask birthing facilities to be flexible, remember the importance of recognizing when it is not the correct or preferred approach, and take appropriate action to provide individualized care.

Baby-Friendly protocols are designed to support appropriate clinical decision-making, not inflexibility or rigid adherence at all cost.

Thank you.