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

The first days after a baby is born are a fragile, critical window for establishing a lifelong connection between mother and child. For many families, this period is defined by the challenge of breastfeeding, a natural process that provides essential nutrition and immune protection for the infant while offering significant health benefits for the mother. Yet, even in hospitals equipped to care for new families, the path to exclusive breastfeeding—where a baby receives only breast milk without any other food or drink—is often uneven. Success depends heavily on consistent guidance, skilled assistance with the physical act of latching, and support that continues after the family leaves the hospital. In many parts of the world, including the Middle East, these supports can be fragmented, leaving parents to navigate confusion, fatigue, and a lack of standardized help. When support is inconsistent, early struggles can quickly erode a mother's confidence, leading to the introduction of formula or other supplements before breastfeeding is firmly established.

In a tertiary care center in Beirut, Lebanon, a team of researchers and clinicians set out to fix this inconsistency. They launched a structured effort to transform how breastfeeding was taught and supported in their hospital's nursery, aiming to turn a variable, provider-dependent practice into a reliable system of care. Their goal was not just to teach staff, but to create a seamless experience for parents that would help more families succeed in breastfeeding exclusively. Over nearly three years, they tested a series of changes, from training nurses and doctors to updating how they recorded feeding details in patient charts. They hoped to see a dramatic rise in the number of babies leaving the hospital with only breast milk, and to keep those babies breastfeeding at home. What they found was a story of successful system changes that did not translate into the expected rise in breastfeeding rates, revealing that the hospital stay itself is often too short to overcome the deeper challenges families face once they return home.

The project began at the American University of Beirut Medical Center, a major hospital serving a wide region, where about 1,000 babies are born each year. Before the intervention, the way staff helped new mothers was inconsistent. One nurse might offer detailed advice on how to hold a baby, while another might simply check the baby's weight. There was no standard checklist, no unified way to measure if a baby was latching correctly, and no guaranteed follow-up after the family went home. The team, led by a group of neonatologists, nurses, and educators, decided to use a method called quality improvement. This approach involves making small, specific changes, watching what happens, and then refining the process based on what they learn. They started by mapping out exactly where the system was breaking down, identifying that the lack of standard training and the absence of a structured follow-up plan were the biggest hurdles.

The team rolled out their changes in four distinct phases over several years. In the first phase, they introduced structured education sessions for the medical staff, ensuring that every nurse and doctor knew the same key points about breastfeeding. They began making phone calls to new parents one week after they left the hospital to check on their progress, a practice that was previously rare. As they moved into the second phase, they tightened the system further. They updated the hospital's electronic health records to include specific fields for documenting breastfeeding positions and the baby's latch. They also changed how formula was ordered; instead of being available on a casual "as needed" basis, it now required a doctor to write a specific reason for its use, ensuring that formula was only given when medically necessary. They also revised the discharge checklist to include breastfeeding goals, making sure every family left with a clear plan.

By the third phase, the team added a more objective tool to their toolkit: a scoring system for the baby's latch. This allowed staff to measure the quality of the feeding technique with a simple number, removing guesswork from the assessment. They continued to reinforce training and expanded their support to include prenatal education, recognizing that waiting until the baby was born might be too late to change a mother's expectations. In the final phase, they worked to make these new habits stick, integrating the training into the orientation for new staff and expanding the support to include the delivery room staff, so that help began the moment a baby was born. Throughout this entire process, they tracked their progress meticulously, counting how many babies were exclusively breastfed, how many follow-up calls were made, and how well the staff was following the new rules.

The results of this multi-year effort were a mix of clear successes and sobering realities. On the side of process, the team achieved exactly what they set out to do. They successfully standardized the way breastfeeding was taught and documented. The staff began using the new scoring system for latching with high consistency, and the electronic records became much more complete. The number of follow-up phone calls to new parents increased dramatically, moving from almost none to over 50 calls a month at the peak of the project. Parents who responded to surveys reported high levels of knowledge and confidence, suggesting that when they were reached, the education was effective.

However, when the team looked at the ultimate goal—the percentage of babies who were exclusively breastfed—the picture was different. Despite all the new training, the new checklists, and the increased follow-up calls, the rate of exclusive breastfeeding in the hospital did not show a sustained upward trend. It hovered between roughly 45% and 55%, fluctuating but never making the leap to the 90% target they had hoped for. Similarly, the rates of exclusive breastfeeding after the families went home remained variable, with no consistent improvement over time. The data showed that while the hospital had become a better place to learn about breastfeeding, the short length of stay—typically just 24 to 48 hours for healthy mothers and babies—was not enough time to cement these habits or overcome the obstacles that arose once the family returned to their daily lives.

When the researchers dug into the reasons why families stopped breastfeeding exclusively, they found that the barriers were rarely medical emergencies. The most common reasons were not that the baby was sick or that the mother had a physical inability to feed, but rather that the mother was tired, or that she simply preferred to mix in formula for convenience. These non-medical factors, driven by maternal preference and fatigue, accounted for the vast majority of cases where formula was introduced. After discharge, the challenges shifted to physical pain, the perception that milk supply was low, and difficulties with the baby latching on. These findings suggested that the hospital interventions, while necessary, were insufficient to change deeply held beliefs or to provide the continuous support needed during the first month of life.

The study concluded that while a hospital can successfully standardize its internal processes and improve the quality of care it delivers, it cannot solve the breastfeeding crisis alone, especially in a setting where families leave the hospital so quickly. The team realized that to truly improve outcomes, the support must start earlier, during pregnancy, and continue seamlessly after discharge. They noted that in their region, the lack of a unified national framework for breastfeeding support and the limited access to specialized lactation consultants after leaving the hospital made it difficult for families to sustain their efforts. The project demonstrated that you can build a better system inside the hospital walls, but without a stronger bridge to the community and earlier prenatal education, the gains made inside the hospital may not last once the family walks out the door.

This work offers a clear lesson for healthcare systems everywhere: improving the quality of care requires looking beyond the immediate moment of delivery. The team in Lebanon showed that they could fix the broken parts of their own system, creating a more reliable and knowledgeable environment for new parents. Yet, the data also showed that the clock of the hospital stay is a powerful constraint. To help more families succeed, the support network must extend far beyond the nursery, reaching into the home and the community, and beginning long before the baby is born. The path forward, as their study suggests, lies in connecting the hospital's expertise with continuous, long-term support that meets families where they are, long after the discharge papers are signed.