In Reply Dr Bartick and colleagues point out a key limitation of our review methodology, which was discussed at length in both our full report1 and article. We set a priori eligibility criteria limiting included study designs to randomized clinical trials, prospective cohort studies, and before-and-after designs with concurrent control groups. There are a number of published evaluations of the BHFI (and other systems-level policies and practices), but they are generally limited to before-after comparisons within single hospitals or ecological studies and thus were excluded from our review. Although these types of study designs can enhance understanding of the relationship between policy implementation and rates of breastfeeding and can suggest avenues of further research, these designs cannot demonstrate causal associations and are often confounded by other important variables such as changes in the underlying population and rates of breastfeeding, other maternity care practices, and the measurement of breastfeeding. Although we agree that randomization of birthing facilities to receive or not receive BFHI accreditation would be logistically and perhaps ethically challenging, more studies using longitudinal, controlled designs that perhaps take advantage of so-called natural experiments are warranted.
Patnode CD, Senger CA. Evidence for the Baby-Friendly Hospital Initiative to Support Breastfeeding—Reply. JAMA. 2017;317(7):771-772. doi:10.1001/jama.2016.20835