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Background: The Baby-Friendly Hospital Initiative (BFHI) has been implemented in Ghana since 1995. At the end of 2011, about 325 maternity facilities in Ghana had been designated Baby Friendly. However, none had been re-assessed for adherence to the Ten Steps to successful breastfeeding (Ten Steps). The current study re-assessed six maternity facilities in Accra for adherence to the Ten Steps and the International Code of Marketing of breast milk substitutes (the Code). Methods: Three independent assessors performed the re-assessment using the revised WHO/UNICEF external re-assessment tool (ERT) between April and June, 2011. All sections of the ERT were implemented, except for the HIV/infant feeding section. Assessors interviewed 90 clinical staff of the facilities, 60 pregnant women, and 150 women who had given birth and waiting to be discharged from the hospital. Additionally, observations were completed on neonate feeding and compliance with the Code. Data was analyzed to assess adherence to the Ten Steps and the Code. Results: In 2010, the six facilities recorded a total of 26,339 deliveries. At discharge, the weighted exclusive breastfeeding rate was 93.8%. None of the facilities adhered completely to the Ten Steps. Overall, the rate of adherence to the Ten Steps was 42% (range = 30 - 70%). No facility met the criteria for Steps One and Two. Only Step Seven was adhered to by all facilities. Overall compliance with the Code was about 54%. Trained staff attrition, high client-staff ratios, inadequate in-service training for new staff, and inadequate support for regional and national program monitoring were identified as barriers to adherence. Conclusion: Poor adherence to Baby-Friendly practices in designated BFHI facilities was observed in urban Accra. Renewed efforts to support monitoring of designated facilities is recommended. [ABSTRACT FROM AUTHOR]