1. Bass, Joel L. MD
  2. Gartley, Tina MD
  3. Kleinman, Ronald MD

Article Content

We read with interest the recent report of Jolies and Hoehn-Velasco1 concerning the value of The Joint Commission breastfeeding exclusivity perinatal core measure and Baby-Friendly certification, as an effective quality strategy and associated "lever" driving performance improvement and enhanced population health.


The authors focus their analysis on the incidence of breastfeeding persistence at 6 and 12 months after discharge and breastfeeding exclusivity in the first 2 days of life, using publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention (CDC) Breastfeeding Report Cards. As a measure of success, they report that between 2008 and 2014, there was an increase in the percentage of births in certified (ie, designated) Baby-Friendly hospitals in the United States from 2.4% to 7.0%, with associated increases in breastfeeding rates at 6 to 12 months, which they imply resulted from the increase in Baby-Friendly designated hospitals.


Given the demographic and cultural heterogeneity of the United States and its territories, as well as the varied approaches to supporting breastfeeding of state and hospital programs throughout the nation, we suggest that using aggregated national data to determine the relationship between breastfeeding rates following postnatal hospital discharge and Baby-Friendly Hospital designation is not appropriate. The small national penetrance of 7.0% of births in hospitals with Baby-Friendly designation strongly supports the ecological fallacy of this approach. During the same time frame, breastfeeding initiation increased from 74.5% to 80.6%, a much larger national penetrance and a more logical explanation for the reported positive breastfeeding outcomes during that time period. In our recent publication, using the same data source and state-by-state penetrance and outcomes, we demonstrated that the states with high breastfeeding initiation rates had very strong associated later breastfeeding outcomes.2 This was not the case for states with high Baby-Friendly penetrance, including those with rates as high as 85.8 to 98.2%. The authors' assumption that breastfeeding initiation ("ever breastfed") is a dependent rather than an independent variable does not account for that possibility. As the authors acknowledge, there are alternate explanations for the outcomes they report, and we suggest that increased breastfeeding initiation rates, independent of Baby-Friendly designation, are the most likely explanation.


In addition, although the authors' state-level event data confirm previous reports that Baby-Friendly designation results in increased exclusive breastfeeding rates during the period of hospitalization following birth, the benefit of that approach as public policy is not realized if enhanced persistence of breastfeeding after discharge is not achieved. Of note, the current World Health Organization (WHO) Baby-Friendly Initiative has recognized this issue in its updated guidance and cites evidence that a small amount of artificial milk fed to infants in hospital following birth makes little or no difference to the success of breastfeeding following discharge.3 It should also be noted that the WHO no longer recommends universal Baby-Friendly designation.4


We do however believe that there is an important role for public policies that encourage birth hospital adoption of some or all of the methods recommended for supporting breastfeeding in the current WHO Baby-Friendly Initiative apart from designation.2 Both CDC and state efforts to encourage and support breastfeeding before, during, and after birth should be the focus of public policy, and, given the evidence, The Joint Commission should shift from focusing on breastfeeding exclusivity to targeted measurement of breastfeeding initiation rates.


-Joel L. Bass, MD


-Tina Gartley, MD


Harvard Medical School


Boston, Massachusetts


Department of Pediatrics


Newton-Wellesley Hospital


Newton, Massachusetts


-Ronald Kleinman, MD


Harvard Medical School


Boston, Massachusetts


Department of Pediatrics


Massachusetts General Hospital


Boston, Massachusetts




1. Jolles DR, Hoehn-Velasco L. Breastfeeding as a quality measure, demonstrating levers of the national quality strategy. J Perinat Neonatal Nurs. 2021;35(3):221-227. [Context Link]


2. Bass JL, Gartley T, Kleinman R. Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: public policy implications. J Pediatr. 2020;218:16-21.e1. [Context Link]


3. World Health Organization. Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva, Switzerland: World Health Organization; 2017. [Context Link]


4. World Health Organization. Implementation Guidance: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services-The Revised Baby-Friendly Hospital Initiative. Geneva, Switzerland: World Health Organization; 2018. [Context Link]