Toward Baby-Friendly care: implementing standardized breastfeeding counseling through a quality improvement initiative at a tertiary care center in Lebanon

<title>Abstract</title> <p>Background The Baby-Friendly Hospital Initiative (BFHI) identifies maternity facilities as a critical platform for protecting, promoting, and supporting breastfeeding. In Lebanon, however, progress toward Baby-Friendly care remains uneven, with suboptimal exclusive breastfeeding (EBF) rates, inconsistent breastfeeding counseling, and limited post-discharge support. Objective To implement a multi-component quality improvement (QI) initiative to standardize breastfeeding counseling and support in a normal nursery at a tertiary care center in Lebanon, as a step toward Baby-Friendly care, and evaluate its impact on breastfeeding outcomes. Methods We conducted a quasi-experimental QI initiative using iterative Plan–Do–Study–Act cycles, aligned with Baby-Friendly Hospital Initiative principles and reported according to SQUIRE 2.0, between April 2023 and December 2025. Interventions targeted healthcare providers and parents and included structured staff education, standardized bedside counseling and competency assessment (including latch scoring), integration of breastfeeding indicators into the electronic health record, revision of supplementation and discharge workflows, and post-discharge follow-up calls at 1 week and 1 month. Outcome measures included in-hospital and post-discharge EBF rates. Process, feasibility, and balancing measures were also assessed. Results In-hospital EBF rates fluctuated without sustained improvement, remaining overall between approximately 45% and 55% despite intermittent increases. Post-discharge EBF rates demonstrated variability, with no consistent trend. Process measures showed substantial improvement, including increased implementation of follow-up calls, high adoption of latch scoring and improved documentation practices. Parental knowledge scores remained relatively high among respondents; however, response rates declined significantly over time. Analysis of in-hospital barriers revealed that non-medical factors, particularly maternal preference and fatigue, accounted for most mixed feeding practices. Post-discharge challenges included nipple pain, perceived low milk supply, and latching difficulties. Conclusion A structured, nursery-based QI approach successfully implemented several practical elements of Baby-Friendly care, including the standardization and delivery of breastfeeding counseling but did not achieve sustained increases in EBF rates. These findings highlight the limited impact of in-hospital interventions alone in settings with short postpartum stays. In Lebanon and similar settings, stronger BFHI-oriented integration through earlier prenatal counseling and continuous post-discharge support is needed to improve breastfeeding outcomes.</p>