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Background: Although the Baby-Friendly Hospital Initiative has improved breastfeeding rates globally, weak monitoring still affects hospital-level implementation. Research aim: To reassess compliance of a Baby-Friendly Hospital with the Ten Steps to Successful Breastfeeding, International Code of Marketing of Breast-milk Substitutes, HIV and Infant Feeding, and Mother-Friendly Care following the WHO/UNICEF global criteria. Methods: In this cross-sectional, prospective, mixed-methods study ( N = 180), clinical staff ( n = 60), pregnant women ( n = 40), postpartum mothers ( n = 60), and mothers of babies in intensive care ( n = 20) were randomly selected from one urban secondary-level public hospital in Ghana designated as Baby-Friendly in 2004 but never reassessed. Data were collected through interviews, document reviews, and observations using the revised WHO/UNICEF external reassessment tool and analyzed quantitatively using the Baby-Friendly Hospital Initiative computer tool. Scores higher than 80% signified a pass (high compliance). Scores rated as low (< 50%) and moderate (50–80%) signified noncompliance. Results: The facility passed the criteria for full compliance with the International Code (86%) but failed other components. Compliance with the Ten Steps was moderate (55%). Step 7 about rooming-in (84%) and Step 9 about human milk substitutes (100%) were passed, whereas Step 1 about written breastfeeding policies (0%), Step 2 about staff training (7%), and Step 4 about early breastfeeding initiation (31%) were met the least. Compliance with Mother-Friendly Care (34%) and HIV and Infant Feeding (47%) were low. Main implementation gaps were unavailability of policies and staff’s inadequate knowledge about Baby-Friendly practices. Conclusions: Improving staff training and maternal counseling, routinely reassessing designated facilities, and providing technical support in problematic areas might sustain implementation.

Introduction : breastfeeding is a key component of infant health through the reduction of morbidity and mortality. In an effort to protect, promote and support breastfeeding the Baby Friendly Hospital Initiative (BFHI) was introduced in 1991, with the development of indicators for evaluating its implementation. For a facility to be designated as baby friendly, it goes through a process and after successful designation, there is periodic reassessment to evaluate adherence to the indicators. In 2015, we reassessed a metropolitan-level health facility in the Greater Accra region which was designated as baby friendly in 2004 to determine whether the ten steps to successful breastfeeding and the international code of marketing breastmilk substitutes referred to as the Code were adhered to. Methods : a cross sectional observational study with 90 respondents comprising 30 postpartum mothers, 20 pregnant women, 30 clinical staff and 10 mothers with babies in neonatal intensive-care were randomly selected and interviewed by a trained assessor using the WHO/UNICEF BFHI tools for external assessment. The WHO/UNICEF BFHI reassessment statistical tool which was used for data analysis records in percentages. Adherence rates were classified as low (0-49%), moderate (50-89%) or high (90-100). Results : overall, adherence to the BFHI was low (38%). Compliance to the ten steps to successful breastfeeding was low (42%); however, there was a high score (100%) for step 9 (no artificial teats or pacifiers). Moderate scores (60%), (83%) and (75%) were recorded for steps; 3(information on breastfeeding to pregnant women), 7(practice rooming in) and 10 (referral to breastfeeding groups in the communities) respectively. Low scores (0%), (4%), (27%), (32%), (8%) were recorded for the remaining steps; 1 (written policy on breastfeeding), 2(training all staff), 5 (show mothers how to breastfeed), 6(give infant no food or drink), 8(breastfeed on demand) respectively. The Code Recorded a moderate score (54%); though a low score (15%) was recorded for code 4 (importance of not giving samples of infant formula to mothers). Conclusion : the facility adhered poorly to the ten steps to successful breastfeeding and the Code of BFHI. Frequent monitoring and evaluation of the facility and capacity building of staff is recommended.