Chanie Fingerer from the Happy Birthway podcast returns to discuss baby-friendly hospitals. She explains what baby-friendly hospital accreditation requires as well as some pros and cons that patients might find. She and Dr. Fox also discuss the couplet model of nursing, how baby-friendly hospitals can increase success in breastfeeding, and more.
“Baby Friendly Hospitals”- with Chanie Fingerer
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Chanie Fingerer from the Yoledet Academy and the “Happy Birthway” podcast. How you doing? Welcome back to the podcast.
Chanie: I’m good. Thank you. Thank you so much for having me again. I’m really honored and I’m honored that you actually listen to my podcast. Like, if anything is affirmation that I know a little bit of what I’m saying, then that’s you.
Dr. Fox: That’s very sweet of you. I appreciate it. Yeah. I mean, I heard your podcast that you did about baby-friendly hospitals and I thought, “Wow, that’s a really good topic to cover.” And I loved your perspective on it and I have some thoughts on it also. And I thought that it would be really good for the listeners of this podcast to hear what you have to say.
Obviously, everyone’s invited to tune into your podcast as well. Again, it’s called “Happy Birthway” podcast. And they can check it out, both the one about baby-friendly as well as your others, and they can also listen to this one. And hopefully, we’ll get them the information we think is important for each family about to have a baby.
Chanie: Yes. Thank you so much. It’s episode 30.
Dr. Fox: So, just for our listeners who might not know who you are, maybe some of our newer listeners who didn’t hear you on the podcast before when you spoke about labor nursing in general, just give us a little bit of background of who is Chanie Fingerer? Who are you? What are you doing?
Chanie: So, I am a labor and delivery nurse out of Connecticut, and I’ve been a nurse for about seven and a half years. I actually became a labor and delivery nurse because I did not have positive birth experiences with my own. You know, some people are inspired to be nurses when they get good care. Unfortunately, mine was the opposite. But, you know, I took it into, you know, kind of, a self-actualization thing and I became obsessed with everything birth starting from when I had my first one 14 and a half years ago. It’s crazy.
I remain passionate about birth and I think that I am able to, kind of, have a more broad perspective about birth, not just… You know, many nurses who are working within their specific hospital, within the specific unit, they, kind of, just see it a little bit more narrow. And I just, you know, from a broader perspective, think about different issues, different policies, and things like that.
And I’m also, you know, like to really function off the precept of empathy and compassion and really understanding the patient experience and having the experiences that I did with my births, you know, really using those to develop compassion and empathy for those who are currently undergoing the process. And, you know, education is very, very dear to me. It’s so important to get the education that you need. You can’t just, you know, rely on your provider because realistically, they don’t have enough time to tell you everything that you need to know.
So, I started my Instagram account a few months after the pandemic started. And it was really very fulfilling to be able to have a greater reach than just the patients that I see in the hospital. Eventually, it led to me starting this podcast that I have, the “Happy Birthway” podcast. And then, I am a podcast fanatic so I have your podcast, which I absolutely love and is so incredible and is, like, so chockful of information. There’s so much that I learn from you. That’s how we found each other.
And I was honored to have you on my podcast. And I was honored to appear in your podcast a little bit a while ago. And I actually just currently launched my website, yoledetacademy.com, and I gave my first workshop, which is called “After the Birth,” which has a lot of the information that, you know, we’ll be talking about regarding the implications of baby-friendly hospitals, etc., you know, more courses to come.
Dr. Fox: So, Chanie, let’s just jump into baby-friendly, because that’s what we’re talking about today. First of all, before we get into what it actually means, what prompted you to even do that podcast on baby-friendly?
Chanie: Well, throughout the time that I’ve been doing all of my little projects, I’ve heard over and over and over again from parents that they absolutely abhor baby-friendly hospitals overwhelmingly so because they think that, A, they didn’t really understand what they are about, but B, I think that they’re, kind of, notorious for not having a nursery. And I think when people hear baby-friendly hospital, what they hear is, is no nursery. And what they translate that to mean is that no support.
So, I had a small conversation on my Instagram account about that because people always love to bring up, you know, and ask me what my opinions are on hospitals with no nurseries. I had a small conversation, but there’s, like, a lot of nuance that’s missing on a platform like Instagram, so I got a lot of angry messages telling me that, you know, “How can I be so unsupportive of mothers, etc., etc.?” So, I took it over to a podcast which enabled me to really explain things, I think, with more nuance and more greater detail.
Dr. Fox: Terrific. So, how would you explain, on a high arching level, what exactly does baby-friendly mean? Because I mean, who would be opposed to a hospital that’s friendly to babies, right? We love babies. Why not be friendly to them?
Chanie: So, baby-friendly is actually an accreditation. There’s a baby-friendly hospital organization and they created this initiative where they meet the 10 precepts of the World Health Organization for successful breastfeeding. And their intention was very good. Their intention was to create a very supportive environment for new mothers when it comes to learning how to breastfeed their babies. But one of the, you know, foundational principles is to not separate mothers from their babies as much as possible.
And so, what happened was, was that baby-friendly hospitals who achieved the baby-friendly accreditation, what they did was they basically closed down their nurseries and they focused very much on what we call couplet care. Because it used to be that there were nurses that cared for the mothers and then separate nurses that cared for the babies. And so, they shifted from that model to a couplet model where a nurse, you have the same nurse that’s both for you and for baby.
So, it’s more, the nurse is able to really give you that support. You’re not seeing extra staff and everyone, you know, and no one knows what’s happening with who. Like, this, you that couplet care. And so, they really started pushing for the, you know, rooming-in, which is great in many ways. However, they started closing down their nurseries and I think started going a little bit overboard, some hospitals.
The other thing that happened is that baby-friendly accreditation cost a lot money. And it’s not something that… It’s not a necessity. So, there are many hospitals that try to use their model, the baby-friendly model, but they’re not actually accredited. And they also started closing down their nurseries because they said that, you know, 24/7 room-in.
So, the benefits of baby-friendly, they are many. They have a lot of education for the staff, extra education than usual about breastfeeding, and providing breastfeeding support. You know, one of the important things that they do is that they make sure that all of the staff has uniform education. Because I hear a lot of times from patients, not necessarily my hospital, but just, you know, followers and other contacts that they were told very different things, and things often in conflict with each other by staff in the hospital.
So, the registered nurse came in and said one thing, the lactation consultant came in and said another thing, the pediatrician came in and said, you know, a third thing. And it was actually contradicting each other, so they were very confused. So, one of the good things is, is that the staff has uniform education and they are up to date with the latest guidelines and recommendations for successful breastfeeding. But again, I think that some parents felt like some of the policies turned a little draconian.
Dr. Fox: Yeah, no. I think that, you know, if you go to the baby-friendly, there’s a website, it’s called babyfriendlyusa.org.
Dr. Fox: And it’s an organization. And again, like you said, it’s an accreditation, meaning a baby-friendly hospital paid to have this group come in and, sort of, assess them to make sure that they’re following. And then they give them, like, a certificate or a label and they can advertise, “We are a baby-friendly hospital.” And then hospitals would do it because it helps them advertise that they’re on board with this and potentially maybe it’ll help their business, you know, more patients will come there or whatever.
But there’s a cost to it, a financial cost as well as training. But a hospital that does not have this accreditation, it does not mean that they’re not doing these things. It might mean they’re not doing these things, but it also just might mean they didn’t want to deal with the accreditation process and they might do it. So, it’s not necessarily true that if there’s the designation versus not the designation, you’ll see different practices. You might, but not necessarily.
And the other thing that’s, I think, really important is if you go to their website, the overall arching principles that they’re using, they list them. There’s three tenets. The first is that breastfeeding is optimal. I think that’s a fair statement. Although I think that sometimes that could be misleading to the point of, sort of, shaming people who don’t breastfeed their children. You know, when you say it’s optimal, it depends what you mean by that.
And we’ve had a bunch of podcasts on that. Exactly what are the benefits of breastfeeding versus bottle feeding and, you know, when are they relevant? When are they not relevant? You know, what’s important? What’s not important? Okay. The second tenet is that the first few days after birth should be about bonding and support and not commercial interest, meaning, try to keep, you know, formula companies out of the postpartum room.
And the third is that every mother should be informed about the importance of breastfeeding and respected to make her own decision. Meaning, one of the three tenets is that breastfeeding is best. And the other one is that, but it’s okay for moms to choose whatever is right for her and her family. And then, in order to achieve those three things, they have these 10 steps, right? Or 10, I don’t know, things you have to do. Let’s list all 10 just so everyone knows we’re talking about. I have the website up, so I’m just gonna basically read them, and then we’ll, sort of, talk about what’s good about it, where it might go wrong, understanding them in context.
So, the first is to comply with this international code of marketing a breast milk substitute, that is from the World Health Assembly. No one’s gonna know what that means, but there is something there. Actually, one is, sort of, in three parts. To have a written infant feeding policy that is communicated to staff and patients. And the third part of one is to establish ongoing monitoring data and management, meaning to, sort of, just double check you’re doing it.
Number two, to educate the staff that they have knowledge, competence, and skills to support breastfeeding. Number three, to discuss the importance and management of breastfeeding with pregnant women and their families. Number four, facilitate immediate and uninterrupted skin-to-skin contact to initiate breastfeeding soon as possible. Number five, support mothers to initiate and maintain breastfeeding and manage common difficulties.
Number six, not giving breastfed newborns any food or fluids other than breast milk unless medically indicated. Number seven, enabling mothers and infants to remain together and to practice rooming-in 24 hours a day. Again, the word here is enable. It doesn’t mean require. Number eight, to support mothers to recognize and respond to their infant’s cues for feedings. So, it’s just, sort of, teaching for breastfeeding.
Number nine, to counsel mothers on the use and risks of bottles, artificial nipples, and pacifiers. And number 10, to coordinate discharge so that parents and their infants have timely access to ongoing supporting care. So, those are the 10. And I think if you read them, yeah, that sounds great. Like, why not? Right? Sounds wonderful. It’s really helping support women who wanna breastfeed. So, what else is good about baby-friendly or these 10 things? You mentioned the standardized education. What else might be good about this?
Chanie: We have that golden hour, the first 60 minutes of life. And I think that baby-friendly hospitals really shifted from the grabbing the baby away from the mother to weigh the baby and do the vitals and all the procedures to really focus on the mother-baby bonding and allowing the baby to remain on the mother, with the mother, and really focus on the important things like breastfeeding as soon as possible, which has been shown to greatly increase the likelihood of success with breastfeeding.
So, you know, that’s really another additional really great thing that I think the baby-friendly hospital initiative has done. And I think that it’s really, really supportive of providing education for mothers on breastfeeding. And that includes sitting through a breastfeeding session and actually watching what’s going on. It includes making sure that there’s sufficient lactation support. And, you know, like you said, it’s important to discriminate between actual baby-friendly accreditation and the fact that there are other hospitals that have not achieved this accreditation but do have a very strong lactation program regardless and do many of these things.
And I think that it’s just that the baby-friendly accreditation actually distinguishes the hospital as being one like that. So, if a mother is looking for having really strong lactation and breastfeeding support, if they have a baby-friendly hospital in their neighborhood, somewhere near them, then, you know, they know that they’ll be able to potentially get that. The accreditation identifies this as a hospital that does that.
Dr. Fox: Yeah. And I think that none of these steps state that the hospital has to have certified lactation consultants in order to achieve this. But I think from a practical level, most hospitals who are going to achieve this are going to try to achieve this are gonna have lactation consultants around on standby, available, you know, meeting with everyone, either routinely or on-demand. These are the people who know it the best and also have time devoted specifically to this.
The postpartum nurses know a ton about breastfeeding obviously. They do this all the time with patients. But they have a lot of other things to do, right? They also have to take care of, are they bleeding? Are they getting outta bed? You know, they have a full catheter. Like, all these things they have to do just in their nursing capacity that breastfeeding and helping women breastfeed is one of the things they do, but it’s not the only thing they do.
So, having lactation consultants on staff is gonna be another way to support women who wanna breastfeed because these are people who that’s what they do. Like, that’s all they’re there to do is to help women breastfeed. They don’t have other responsibilities. And so, I think most of the baby-friendly hospitals will probably have lactation consultants. And again, many of the hospitals that aren’t “baby-friendly” also have lactation consultants.
So, that might be a question to ask if, let’s say, you’re delivering at a hospital that doesn’t have this distinction but you are very motivated to breastfeed, that’s a question you could ask. “Okay, you’re not baby-friendly. But do you have lactation consultants in the hospital? Are they available? You know, how easy is it to meet with one? Is it…? Are they there every day?” You know, things like that, because if that’s the case, then all right, at least you know you can get that support even if they don’t have that distinction, so to speak.
Chanie: Correct. And I think it’s important to note that, you know, lactation consultants, like you said, they have advanced training in breastfeeding. And there can be postpartum nurses. There are nurses, you know, in many specialties that actually have that same advanced training and they are also a certified lactation consultant. So, while they don’t function in that role specifically in the hospital, they may be taking care of you, a lot of the nurses may actually be certified as the lactation consultant.
And usually, it’s the lactation consultants in a hospital that are driving the hospital toward this baby-friendly accreditation. And usually, they are the ones that are actually qualified to educate, to provide the lactation education. So, of course, like you said, there’s no actual writing in the baby-friendly accreditation criteria that they have to have specifically lactation consultants but those are the ones that are qualified to provide the education throughout the hospital.
Dr. Fox: And it’s also important to distinguish, when we talk about education, it’s education, not just for the breastfeeding women, but for the staff. Education is not just providing the person who wants to breastfeed education. It means everyone on the staff is getting similar education and training.
So, like you said, the messaging is uniform so that, again, there’s always some differences in opinions on what’s the best way to go about A, B, C or D. But in terms of the general knowledge, it should raise everybody who’s interacting with the new mom to the same level of knowledge and also, sort of, on the same page with what everyone’s been taught about breastfeeding so you’re getting a much more uniform message and education as the new nursing mom.
Chanie: Correct. Correct. And the staff education is vital. Where I work, we have at least twice a year where we really have, like, extensive, a good hour or two of lactation education. And as you know, science changes, evidence changes. We learn more as we go. So, recommendations for breastfeeding change as well.
You know, and we run through different scenarios so that we can, let’s say, a NICU baby, or, you know, a very sick mother, whatever it may be, we run through different scenarios to troubleshoot and understand how to best deal with those scenarios. The postpartum nurses, the labor and delivery nurses, we’re the end-users of that education. So, we take all of that education we receive from lactation consultants, who may not necessarily be in contact with every single patient, but we are the ones that take that education to the patient themselves.
Dr. Fox: Where can baby-friendly go wrong? Because what we’re talking about sounds great, right? There’s… It all seems very, very positive and supportive and welcoming and wonderful. But it can go wrong. And so, how might that happen and how can we try to avoid that?
Chanie: Besides for the nursery piece that we discussed, which I wanna circle back to in a minute, unfortunately, there develops this culture of judgment around breastfeeding and mothers who choose to breastfeed or not, or mothers who choose not to breastfeed. And I think that, you know, especially with COVID, I was seeing a lot of parents who were requesting, one of the hospitals I work at, they do have a nursery, not always, but on occasion. And, you know, nurses were judging parents who requested to have their babies brought out.
They were actually planning on exclusively breastfeeding. The parents were just asking to have their baby out for, like, two hours so they can sleep. But even over there, the staff was, kind of, being all… And I don’t work in a baby-friendly hospital, so this extends to hospitals that are not baby-friendly. The staff can get judgmental and the parents can feel it. They can feel judged. I’ve had people who told me that when they asked for their baby to even just go out of their room for an hour or two, they got reactions from staff.
They got a whole speech. Like, it was this whole entire speech about how they’re not gonna bond with their baby well, etc., etc. And these are new moms that are hormonal, that are exhausted from days of no sleep and hard work with giving birth. And now they’re being told that they’re gonna be a failure as a parent for the rest of their child’s life because they’re asking for some relief.
And with breastfeeding as well, any parent that comes into the hospital that says that they want to exclusively breastfeed their child, if they change their mind throughout the duration of their stay in the hospital and ask for formula, they can feel like they’re met with a lot of judgment. Many hospitals require that there be a separate order from the pediatrician or a pediatric, any pediatric provider for feeding the baby formula.
So, what the process in place is a lot of times is that they actually have to have a bedside consultation by either a pediatrician or a pediatric PA discussing the harms and risks of feeding their baby formula before they even get the order into the computer system. And then, only then, can they get a bottle of formula for their baby. And that also makes them feel judged.
I actually had a coworker who came from a hospital that, you know, didn’t have that policy in place. And she said, “You know, in our hospital, we have patients sign informed consent for, like, inductions and trying to have a VBAC.” She said, “In this hospital, they don’t have you sign informed consents for that. They have you sign an informed consent form for understanding the dangers of feeding your baby formula.” So, yeah, it was, kind of, like, you know, maybe we should reassess our priorities of which kinds of forms you sign.
But parents do feel judged and do feel unsupported when they make a choice that’s not to exclusively breastfeed their baby. And I think that sometimes, the hospital can get caught up in the actual statistics and the numbers. So, they wanna keep their numbers good. I don’t know if this is just a Connecticut thing but I’d imagine it’s in other states too where we actually report our exclusive breastfeeding rates.
So, mother that comes into the hospital, on her admission, she says that she would like to exclusively breastfeed her baby. If anytime within the next…her two or three-day stay she decides that she does wanna supplement with formula, that’s gonna mess up the numbers and lower the exclusive breastfeeding rate for the hospital. And, you know, they don’t like that. They wanna keep their numbers up.
Dr. Fox: Yeah. I mean, we had a whole podcast on this exact thing with the author, Dr. Jung, which was a book called “Lactivism.” And I urge everyone listening, if you’re interested in this topic, to go back to those podcasts from the last, well, I guess two years ago now. But, you know, I think part of the problem is if you look at the tenets of baby-friendly, right? They have a tenet…
One of the three tenets is the mother should be informed about the importance of breastfeeding and respected to make her own decisions. Okay. You know, we should respect her. But when the first thing is that breastfeeding is optimal. It’s the best, right? When doctors, nurses, healthcare providers hear something is the best, that means that anything else is a problem. And I think if they switch the wording from breastfeeding is optimal to breastfeeding is wonderful, I think it would change everything.
Because it’s wonderful to breastfeed. I mean, I think it’s fantastic. It’s healthy. There’s bonding. It’s a tremendous experience for women. It’s healthy. It’s great. But when you start saying it’s better than formula. First of all, we don’t know That’s really true. Like, the data on that’s pretty weak. But then you start making judgements. Okay. Now someone is choosing something that’s worse for her child. It’s like, yeah, people are gonna start judging the moms for picking something that they now think is worse.
That’s part of the problem. That we spend so much time in this education piece trying to convince everybody that breastfeeding is the best and healthiest thing for their baby. And so, therefore, if anyone is not doing it, they’re therefore doing something that’s not good for their baby. And I just think that that’s so misleading and it’s just not genuine. It’s really not fair to, sort of, label it that way. And I think that’s where a lot of this comes up. And if we stopped ranking what’s best and just say that breastfeeding is wonderful and terrific and we’re gonna support you, if someone says they don’t wanna do it, fine. Like, whatever. You’d still be a wonderful parent and have a healthy baby. And it’s not gonna be such a big deal.
Chanie: I see a lot of times parents asking for formula when they originally intended to breastfeed and it’s still their desire because they did not receive the appropriate support to do so. So, for them, it’s not working because they’re not receiving the support that they need to make it work. So, now, for them, formula is a better way of feeding their child because they’re not able to breastfeed in a way that’s working for their baby and themselves.
And if we don’t give them and provide them with that support, even though they intended to breastfeed, then they’re gonna feed with formula. So, you know, I think that we have to look at the intentions and desires of parents and also really do everything we can to uphold their desires and support them in it. So, I have parents who have told me, you know, years after they had their baby, that, for example, the second night, the second day of a baby’s life is really when their stomach is growing and they’re becoming more awake and they can start being starving and so hungry.
And they can… It can feel like they’re breastfeeding more than they’re not breastfeeding on that second day of life. And that’s not something that’s gonna last forever, but it can feel unbearable if you don’t know that. So, parents start to think that, oh my gosh, like, their nipples are sore and they’re exhausted. They can barely get up to go to the bathroom because the baby is just crying all day long.
And if they don’t have the support and education to know that this is transient, this is temporary, in another day or two when their milk comes in, it’s gonna be so much better, then they’re gonna quit. They’re gonna want to formula feed because they say, like, “This is not what I signed up for. I wanted to breastfeed my baby, but I can’t do it at the expense of my mental health and physical health,” you know.
And I’ve told parents that something else that’s important to know is that breastfeeding is where you have to put in the work and lay out the investment, and you don’t reap the benefits of the investment for the first few weeks. I mean, you may, but, you know, sometimes parents quit two or three weeks in when it’s so difficult. It’s so hard. But if they only waited another week or two, then they would reap those benefits of that investment.
And so, again, if parents don’t know this, if they’re not supported all the way and then they want to bottle feed. And I’ve gotten letters from parents a year after they had their baby, mothers who said that, “Thank you so much for letting me know this because if you had not told me this, then I would have quit. And I ended up breastfeeding my baby for a year.”
Dr. Fox: Let me ask you a question. What do you think about the term baby-friendly? I’m not a fan of it. I mean, I like babies, but I don’t like the term baby-friendly. I think, again, because it implies that if you’re a hospital that doesn’t have this distinction, what are you, baby-unfriendly? Like, we don’t like babies or the staff is unfriendly? I don’t know if you’ve thought about these marketing-type things. I think about this a lot because, you know, I’m, kind of, a pain in the butt with these things. But they’re like, “Oh, our hospital’s baby-friendly.” I was like, “Well, were we unfriendly before?”
Chanie: I have to agree with you on that. I think that family-friendly is really what we should aim for. As a nurse in nursing school, I hear this all the time where we need to provide patient-centered care, family-centered care. We need to include the patient in their plan of care and we need to uphold their autonomy in making decisions about their health. And so, when we say baby-friendly, it almost feels like we’re overlooking the mother’s needs.
Dr. Fox: I was gonna ask you that next. I was gonna say, what about mother-friendly? So, I like family-friendly. I think that that’s fantastic. And I think that, you know, some of the things of marketing, again, these are all well-intentioned things, right? People are trying to do the right thing by, you know, women and their babies and their families. And so, I don’t think anyone’s being nefarious here. I think that everyone’s trying to do the right thing. But I remember I was…
I just have this vivid experience when I was taking care of a patient who was in labor. And at the time, they had all these signs. This is right when our hospital had this baby-friendly distinction bestowed upon it. And they had all these signs hanging up on the wall, you know, breast is best. Everyone can breastfeed their baby, you know, all these wonderful things and pictures of mothers breastfeeding, and it’s beautiful. And the mother who was laboring, the poor thing, she’s HIV-positive, right? And they’re recommending not to breastfeed.
And she’s looking at this and she’s like, “Great.” She’s like, “Thanks. You know, like, not only do I have HIV, not only can I not breastfeed my baby, but now I gotta be told that this is somehow bad, that I’m not gonna breastfeed my baby? Like, thank you hospital for just shoving this in my face.” And I think that, again, that’s an unintended consequence of when you try to encourage one group of people, it may not fit for somebody else and it may turn into shame instead of what it should be, which is support.
And I just think that everyone has to be very mindful of these things. When we, you know, try to implement systems that are meant to be helpful, that there can be a ripple effect for people. Like you said, sometimes it’s shaming or sometimes, and we’ll talk about the nursery, that that can go wrong. Or sometimes, with these labels, or if it doesn’t work for someone, that it can sometimes cause harm. And I think we have to be very, very careful with these types of initiatives.
Chanie: Yeah. I agree. I mean, anything, when you take it to the extreme, it doesn’t go well. And it has to be done with balance. And I agree with you. It was a very well-intentioned initiative and project because there wasn’t a lot of breastfeeding support years ago as much as there is today. Parents were just told, “Oh, your baby’s crying? Just give them a bottle.” When in fact, if they got enough support and education, they may have been able to achieve their original goals about breastfeeding. So, I do think it was well-intentioned, but at the same time, we can take it to an extreme, which like you said, can be very harmful.
Dr. Fox: Yeah. And I’m not… I wanna be clear. I’m not saying that I don’t like baby-friendly as a concept. I think it’s fantastic to really get hospitals on the same page in terms of an education, in terms of support, to achieve what they’re trying to achieve, which is to help women breastfeed. But the point is it’s, if that’s what they wanna do. Right? Whereas if they don’t wanna do it, okay. Like, it’s not relevant to you. That’s okay. Move on. Like, next. And I think that that’s really the point that something that’s very good can be “weaponized” to harm someone else.
I wanna talk about the nursery because, like you said, this was, sort of, the driving force for you originally. And I think that this is one of the areas where I don’t believe that the baby-friendly initiative intended to mean nor does it state that babies must room-in with the mothers. It just means that they have the opportunity to room-in with the mother’s 24/7. To enable it. That it’s a possibility. That you can do it. Not that it must be done. Because there’s a lot of reasons that a baby should not room-in with the mother 24/7 in the first two days after birth.
One of those reasons is she’s just… She needs to sleep. Right? If she had a very hard labor, she had a C-section, she’s in pain, she may not be up to it and ready to get up every couple hours and feed the baby. And she may need that rest for her wellbeing to start nursing the next day, for example. Whatever it is, there’s good reasons why mothers might not be ready to have rooming-in right away. And to force it upon them is a lot different than to enable them. Those are very, very different concepts. Are you seeing the same, I don’t know, misuse of that tenet?
Chanie: Yes. Yes. Very much. Now, the Baby-Friendly USA, they every so often update their, you know, criteria, recommendations, education, and what hospitals need to know in order to meet the guidelines to achieve this accreditation. And in 2018, they came out with new guidelines or they revised some things. And I don’t know if this was in the original guidelines, but I’m looking at page 74 from the Baby-Friendly Hospital Initiative, it’s the sixth edition.
And it says here very clearly at the bottom, when they talk about separation and bringing in that medically justifiable or safety-related reasons for separation, they say healthcare professionals must use their clinical judgment. While it is true that rooming-in is the expected practice in baby-friendly designated facilities, we recognize some circumstances necessitate mother-baby separation. The decision that leads to a separation is often complex, involving observations, assessments, and an understanding of the individual mother-baby dyad, dyad means, you know, couplet.
And it says, it is imperative in these situations that care and decisions are individualized and include the mother’s participation if possible. And the last sentence is facilities should have a dedicated area to provide care to infants who have a justifiable reason for separation. Now, the word justifiable again, is a little triggering here because who’s deciding what’s justifiable or not. But at the same time, they write that they… It says, “As a reminder, BFUSA does not require that facilities close their nursery.” So, this is important to know, but I think that throughout the USA, the culture is shifting toward closing nurseries. And I do have a…this is a personal opinion of mine, but I do have a hunch that a big part of it is really finances.
Dr. Fox: Oh, yeah. No, I don’t think that’s a hunch. I think that that’s a reality. I think that COVID torpedoed this because COVID, sort of, was the first reason to say, you know, “We’ll just keep the mother and baby together. Don’t let babies get infected from other babies. Like, keep everyone separate, keep everyone locked in their room together.” And then when that was starting to ease up, there was a huge staffing shortage all over. And so, hospitals couldn’t find nurses to work and there just wasn’t, you know, enough staffing.
And so, the first thing that’s gonna go is the nursery because, right, we got the babies in with the moms. We don’t need as much staff in the nursery. It’s not life or death. So, let’s, sort of, take the nurses out of there because we need them on the postpartum floors and on the labor floor or someone’s out with COVID themselves or whatever it is. And that’s, sort of, the first thing to go. But then you either have a nursery that’s closed or a nursery that’s ostensibly open, but there’s no staff for it. So, it’s essentially closed. That’s why this problem has, sort of, been magnified over the past couple of years, I would say much more so than it was two or three years ago. I don’t think two or three years ago, in baby-friendly hospitals, it was as much an issue as it is now.
Chanie: No, but it was, I have to say, years before COVID happened. Yes. Like you said, COVID magnified this problem. But years before, hospitals were already shutting down their nurseries. I mean, I remember eight years ago, nine years ago when I was in nursing school, a premium New York City hospital that had this designation, they had a newborn observation room, they said.
And, you know, their justifiable reason was that your baby had to have some kind of medical problem that doesn’t necessitate a NICU admission, but it has to be some problem where they’re gonna observe your newborn. But they were shutting them down already at that time. And like I said, other hospitals were piggybacking off of that and using it as, kind of, like an excuse but I feel like maybe a cover-up too, where, “We just wanna save money.”
But I have to say that if you’re having, say, staffing ratios, then you still have to use that extra nurse that you have used for the nursery and to divide the patient assignment to still meet a safe patient assignment where the nurse can, practically speaking, provide that support. Because if I have too many patients and I have to prioritize, so I’m not gonna have time to watch a 30-minute breastfeeding session of one of my patients when I have another patient that’s very sick and, you know, possibly will hemorrhage or another patient that’s getting up for the first time after having the C-section and needs me to help her walk and get to the bathroom, etc., or patients that require their medications.
I’m gonna have to prioritize those things over supporting a mother that needs help with breastfeeding. So, you can provide all the education in the world to your staff. But if, realistically speaking, they don’t have enough time, then they’re not gonna be able to provide one iota of that education and support that you intend for them to provide. And that’s why, as a nurse who really comes face to face with the consequences of the short staffing crisis that we have now, but that we’ve had even before COVID, I wish that the BFUSA would include some kinds of staffing ratio requirement. Because we can’t do our job, we can’t educate the patients the way we need to, if we don’t have enough staffing to cover for it. Because unfortunately, this is one of the first things that will go out the window.
Dr. Fox: Yeah. Yeah. No, it’s a really important point. You know? So, for example, let’s say you had a postpartum unit that originally had six nurses to take care of the postpartum women and two nurses covering the nursery. I don’t know. Let’s say that was the case. If a hospital’s gonna decide, “Hey, we believe that the right thing to do for the women and their babies is to close the nursery,” although we disagree with that, but let’s say they believe that.
All right. Now you should take those two nurses and make it eight nurses covering the same number of women. Because it’s the same number of women and babies, right? That hasn’t changed. So, if you’re gonna take the two nurses out from the nursery, you should have them added to the pool of people who are taking care of the mothers and babies on the floor so at least you maintain the same staffing. But probably, like you said, that doesn’t happen. They just, you know, instead of having six plus two, now they have six plus zero, and that’s it, for the same number of people.
Dr. Fox: And that’s tough. And like you said, you know, the postpartum nurses, when they’re not attending to someone who’s, you know, needs to nurse or has questions, and not because they’re sitting around smoking in the hallway, right? That’s not what’s happening. They’re with somebody else who needs a medication, who needs an antibiotic, who needs help getting outta bed, who fell, who’s bleeding, who’s in pain, who’s getting discharged and needs instructions. Like, there’s things that the nurses have to do.
And if there isn’t enough time to do the other things, they have to prioritize the person who’s bleeding heavily over the person who’s nursing. It’s just how it is. That’s what you would want if you were bleeding heavily. And so, it is a lot about staffing. And this is complicated and neither of us own or run a hospital and, you know what I’m saying? Like, okay. Like, it’s not an issue of blame, but that’s just… These are just the facts. That it’s gonna be hard to achieve this without the proper staffing available to lend that support.
Chanie: Correct. And I have to say, this also extends to the staff developing resentments because their responsibilities are increased because, you know, they have a greater patient load. And unfortunately, that resentment often turns into that judgment that parents experience. So, if the parent will ask if their baby can go out and, you know, be watched or whatever it is for two hours because, you know, I mean, where else would you expect someone who had surgery, major surgery, to then go and take care of a newborn baby and keep it alive? Right?
Dr. Fox: Can you imagine if someone just had their colon removed, they’re in the surgical floor, and someone says, “Here, we’re wheeling in a newborn for you to take care of?”
Chanie: Correct. Right.
Dr. Fox: I don’t think that’s gonna happen. You wouldn’t let him take care of a goldfish, you know, after surgery.
Chanie: Right. Exactly. And, you know, a C-section is not a little laparoscopic surgery. I mean, it’s major open surgery. But I will see, I will witness staff being extremely judgmental of these mothers. Like, you know, I’ve heard them say, “Oh my gosh, like, they think we’re their babysitters. We’re not their babysitters.” No. The staff is most definitely not the patient’s babysitters. But the problem is, is when a patient is in a hospital, they’re not in their own turf. They’re not in their own environment. They’re bound by the policies and rules of the hospital and the way the hospital runs.
So, if at home they’d have had their sister and mother present with them and helping out and cooking meals and, you know, doing all the things that they need, they can’t have that in the hospital. And so, they don’t have the same support setup in the hospital that they would at home. So, they need some other form of support. So, you know, it’s not that they’re being neglectful or ways you are expecting the nurses to babysit their baby, but they still require support. And the hospital, unfortunately, many are not set up for that, you know?
So, I think that we need to take all of this into consideration. Where they’re not asking for their baby to be babysat, but they would have other arrangements at home that they don’t have. And let me ask you this, the hospital that you work at, do they room…? Is it a single room or do they have double rooms too?
Dr. Fox: It’s predominantly double rooms. When COVID hit, they went to single rooms, but also they had a much lower volume. And now to get a single room, you either just have to be lucky that there’s fewer women who delivered or pay for a private room, which is how it was before COVID as well. But the standard is a double room. And so, you can’t have someone sleep over with you. You’re alone at night.
Chanie: Not only can you not have someone sleep over with you, but if you finally get your baby to sleep and then your roommate’s baby starts crying and they have twins and they’re both screaming on top of their lungs, like, then you can’t sleep. You wouldn’t have that when you’re home. So, in my opinion, you know, if the hospital’s gonna have baby-friendly accreditation, they better give the moms single rooms so that they can actually get to sleep when they have the opportunity to.
Dr. Fox: Oh. There goes New York City. Right?
Chanie: I know. No, no, no. I hear you all the way. So, then, like, if those are limitations, then another New York City limitation should be, “Let’s not close the nurseries.”
Dr. Fox: Yeah. No, baby-friendly, I mean, I’m sure that there’s a lot of discussion about things that they want and then they said it’s just not practical. Because some hospitals, we can’t… I’m sure that they’re like, “Listen, we can’t put in staffing because some hospitals can’t afford that and then they’re not gonna be able to get the distinction.” Or, “We can’t do the room-in because some hospitals don’t have the space. And so, they have to… They’re trying to balance, sort of, what they can achieve and what they can’t. You know, it’s…
Listen, it’s hard and it’s part of the downside of these accreditations. You have to make a list of things and what’s on the list and what’s not on the list. And there’s probably a lot of, you know, finance and politics and whatnot that dictates or, sort of, weighs into what’s gonna be on this list. I’m curious just because, you know, we’ve spoken about this for a while and people who are listening who are, let’s say, you know, pregnant and choosing a hospital where they deliver or they’re set to deliver at a certain hospital, should people care if their hospital’s baby-friendly? Like, does it matter? Should someone actually call up and find out or look on their website?
Chanie: So, here’s a few thoughts. Firstly, it is so important to make the point of contact with lactation support and education when you’re pregnant way before you actually enter the hospital doors. And this is another part of this problem. Sometimes, we feel like the burden is all on us, on that postpartum unit, to provide all the support that a patient can get with breastfeeding. But the education and understanding of how breastfeeding works and the benefits, etc., all has to start happening way before that.
So, before you even go into thinking about a baby-friendly hospital, make a point of contact with a lactation consultant beforehand. And you can get those recommendations either from your OB/GYN or a pediatrician that you’re planning on using, even if it’s your first child. A lot of the times, pediatricians have meet and greets that you can meet with them. And a lot of pediatric offices do have lactation consultants on staff as well. But make that point of contact way before.
And a lot of times, lactation consultants in your area will know which hospitals are really supportive with breastfeeding in a supportive way. And so, it might be an extra bonus if you find out a hospital that you might deliver in is baby-friendly, but it’s so much more than that. And as we discussed before, there are many hospitals with fantastic lactation programs that they don’t have their accreditation, but they have a tremendous support.
And there are lactation consultants in other hospitals that still have very weak support, you know? The lactation consultants will stroll in, you know, hang out for four hours on the unit, and then just go home and they won’t be there over the weekends. And the nursing staff won’t really get a lot of support. So, even if there are lactation consultants. So, I think it’s really hard to know. Like, this is something that I as a nurse working in somewhere will be able to identify.
So, someone who’s a lactation consultant, they will also, if you trust them and you develop a rapport and relationship with them, they will also be great resources in helping you figure out a hospital that can provide that support. And a lot of times, there are lactation consultants that simultaneously work at a hospital and then have a private practice outside of the hospital. And that can actually be the best thing if you have a relationship with them because they can help you both in the hospital and then know you, and you’ll have that continuity of care.
So, baby-friendly might be a great bonus, but don’t just focus on that. Like, if location matters to you, if insurance matters to you, if a doctor or a midwife matters to you, then take those into consideration as well. It shouldn’t be the be all end all decision for you.
Dr. Fox: Yeah. I think the point of the baby-friendly distinction is more as, like, the net under the tight rope. It’s, sort of, to catch the people who fall through the cracks and don’t really think much about whether they want to breastfeed or not, and they just, sort of, deliver and it’s the first time they ever really consider it. And having a baby-friendly hospital is gonna be much more encouraging and supportive of them starting. But I think for someone who’s listening and thinking about this in advance, the more important thing to think about and decision to make is how important is breastfeeding to me.
And if the answer is very, right, “I really wanna do it,” then I don’t think it matters so much if it’s baby-friendly. I think it matters when you say, “Okay, this is something that’s important to me. So, I’m gonna learn about it. I’m gonna read about it, maybe have a lactation consultant beforehand or ask my nurse, you know, my midwife, my obstetrician, “Hey, what support is available in the hospital? Are there lactation consultants? Are there not? Are the nurses helpful or not?” And, sort of, get that so as you know what you’re getting into.
And if you find out, “Hey, I’m delivering somewhere with a ton of support. All right, I’ll be great.” Or if you find out not so much support, you’re like, “Okay. That means I need to really boost up my support on the frontend to make sure that it’s gonna happen for me.” And I think that that’s the bigger thing here, to make a decision before you deliver. What do I wanna do? What are my goals? What are my expectations?
So you’ll be able to make sure that they’re met and not relying on baby-friendly to get it done for you. Again, if you don’t think about it at all, sure. Probably if you land in a baby-friendly hospital or one that has support services similar to a baby-friendly hospital, it’ll probably work out better for you breastfeeding. But if you are thinking about it in advance, it probably won’t matter as much.
Chanie: Yeah. And for many people, they don’t even know why they should or shouldn’t breastfeed, you know, if it’s their first baby. I think a lot of our attitudes about breastfeeding come from our socioeconomic backgrounds. You know, family has been shown to be a huge contributor to whether somebody wants to breastfeed or not. Like, if their mother and sisters and everybody around them breastfeeds, then they are likely going to want to breastfeed more.
But a lot of people, they don’t know why they should breastfeed. They don’t know what the benefits are. They don’t know anything. So, like you said, it’s so important to receive that education beforehand so that you know whether or not, or how much of a priority it is for you in general. So, I like to say in many OB/GYN offices, they have, like, other disciplines as support. For example, nutritionists on staff. Someone who’s diagnosed with gestational diabetes or has some other metabolic concerns, they’ll be referred for a nutritional consult.
I’ve never heard of an office that has lactation consultants on staff, but I think it would be so wonderful if someone can get a referral and be encouraged to see one so that they can learn all about this beforehand and so that they have a point of contact. So, you know, maybe you might have some challenges breastfeeding in the beginning, maybe you may not have challenges of breastfeeding in the beginning, but after you get home from the hospital, you may develop new challenges and issues that you’ll want addressed. If you don’t have the point of contact, the professional to help you, it can be so much more chaotic and stressful.
Dr. Fox: Thank you so much for coming on the podcast. I love talking to you. I think you have a great perspective. I love what you’re doing, trying to educate people about birth and about labor. And I just think it’s terrific. And I think that this is a really important topic. Again, I am not opposed to baby-friendly. I am pro baby-friendly. I just think that it’s important for people to understand what that means and what to expect, and where it can go right and where it can go wrong. And I think if people are knowledgeable about that, it’s really gonna make it a much better experience, again, whether they do land in a baby-friendly hospital or not versus not understanding exactly what that means. So, thank you for coming on, Chanie. Always good to talk to you.
Chanie: Thank you so much, Dr. Fox. It’s really an honor.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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