Knowledge, Attitude and Practice of Healthcare Providers Regarding Baby-Friendly Hospital Initiative (BFHI) Practices in the Gaza Strip, Palestine: A Cross-Sectional Study

Breastfeeding is one of the most natural and powerful ways to nourish a newborn, offering protection against illness for the baby and long-term health benefits for the mother. For decades, scientists have known that breast milk provides the perfect balance of nutrients and antibodies, and that feeding a baby exclusively with breast milk for the first six months of life is the gold standard for health. To help mothers succeed, the World Health Organization and UNICEF created a global plan called the Baby-Friendly Hospital Initiative. This program trains hospitals and clinics to support breastfeeding by ensuring that mothers are taught how to feed their babies immediately after birth, that they are not given unnecessary formula, and that they receive consistent, encouraging advice from the staff who care for them. The success of this plan relies entirely on the people working in these facilities: the doctors, nurses, and pharmacists who guide new parents. If these providers do not understand the rules or believe in the methods, the system cannot work, and mothers may miss out on the chance to breastfeed successfully.

In the Gaza Strip, researchers wanted to see how well the healthcare workers were actually doing. They asked a simple but vital question: Do the doctors, nurses, and pharmacists working in hospitals and health centers know the right things, believe in the right ideas, and practice the right behaviors to support breastfeeding? To find out, a team of investigators visited medical facilities across the region between August and December 2022. They spoke directly with 369 healthcare providers, including physicians, pharmacists, and nurses, asking them a series of questions about their knowledge, their attitudes, and their daily habits. The goal was to measure how much these workers knew about the Baby-Friendly Hospital Initiative and whether their training made a difference in how they supported mothers.

The results revealed a mixed picture. Overall, the healthcare providers had a moderate level of understanding, with an average score of about 67 percent. While most of them knew the most famous rule—that breastfeeding should start within the first half hour after birth—many were unsure about the finer details. For instance, only about half of the providers had even heard of the Baby-Friendly Hospital Initiative itself, despite working in facilities that were supposed to be designated as such. There were also significant gaps in their advice regarding when to introduce other foods to a baby and whether it was okay to give a baby water before six months of age. Perhaps most concerning was a common misconception about feeding schedules: nearly two-thirds of the providers believed that mothers should feed their babies on a strict clock, every two or three hours, rather than feeding whenever the baby showed signs of hunger. This advice, if followed, can actually reduce a mother's milk supply and shorten the time she is able to breastfeed exclusively.

The study also showed that where a provider worked and what their job title was mattered greatly. Nurses, who are often the first point of contact for new mothers, scored the highest on knowledge and practice. Doctors came in second, while pharmacists scored the lowest by a wide margin. The location of the workplace made an even bigger difference. Providers working in hospitals that had fully adopted the Baby-Friendly Hospital Initiative scored significantly higher than those working in primary health care centers that had not yet fully implemented the program. The gap was clear: those in the designated hospitals knew more, believed more strongly in the methods, and practiced them more often than their colleagues in other settings.

However, the most powerful factor of all was training. The researchers found a strong link between whether a provider had taken a specific course on the Baby-Friendly Hospital Initiative and how well they performed. Among the providers who had the best scores, more than 90 percent had received this specialized training. In contrast, among those who had the biggest gaps in their knowledge and practice, only a tiny fraction had been trained. This suggests that simply having a medical degree or working in a hospital is not enough; the specific education on how to support breastfeeding is what truly shapes a provider's ability to help. The study also noted that a small but notable number of providers had been approached by representatives from formula milk companies to promote artificial milk, and some had even advised mothers to use it, which goes against the rules designed to protect breastfeeding.

The researchers concluded that the key to improving breastfeeding support in the region is not just to rely on the existing workforce, but to expand training to everyone, especially those in health centers, doctors, and pharmacists who currently lag behind. The findings suggest that if more providers receive this specific education, the quality of care for new mothers will rise, helping to ensure that more families can benefit from the natural advantages of breastfeeding. While the study could not prove that training causes better results in every single case, the connection was so strong and consistent that it points clearly toward training as the most effective tool for change. By focusing on education and ensuring that the rules of the Baby-Friendly Hospital Initiative are understood and practiced by every staff member, the healthcare system in Gaza can build a stronger foundation for the health of its mothers and children.