Barriers and Facilitators to the Implementation and Scale-Up of the Baby-Friendly Hospital Initiative: A Qualitative Study in Saskatchewan, Canada

Abstract

Highlights What are the main findings? This study identified five interconnected domains influencing BFHI implementation in Saskatchewan, Canada, including leadership and governance, workforce capacity, continuity of care, maternal psychosocial experiences, and structural determinants of breastfeeding support. Successful BFHI scale-up was facilitated by strong leadership, standardized breastfeeding practices, skilled providers, interdisciplinary collaboration, and community-based services, while barriers included workforce shortages, fragmented care pathways, inequities in access, and limited system monitoring. What are the implications of the main findings? Sustainable BFHI implementation requires coordinated health system strategies that extend beyond individual provider training to strengthen leadership, workforce capacity, accountability, and integrated maternity care pathways. Embedding BFHI principles into routine healthcare systems can enhance equitable access to breastfeeding support and improve experiences and outcomes for diverse families. Abstract Background: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization (WHO) and UNICEF, provides an evidence-based framework to protect, promote, and support breastfeeding through implementation of the Ten Steps to Successful Breastfeeding. Despite its global adoption, implementation and scale-up of BFHI remain inconsistent across healthcare systems. In Saskatchewan, Canada, only one healthcare facility currently holds BFHI designation, highlighting the need to understand the health system factors influencing implementation. This study aimed to explore the barriers and facilitators influencing the implementation and scale-up of BFHI within Saskatchewan healthcare settings. Methods: A qualitative descriptive study was conducted using Bronfenbrenner’s socioecological model as a guiding theoretical framework. Semi-structured interviews were conducted with 26 mothers and healthcare professionals with breastfeeding-related experiences in Saskatchewan, including 11 mothers (42.3%), 6 mothers who were also healthcare professionals (23.1%), and 9 healthcare professionals without maternal experience (34.6%). Participants were recruited using purposive and maximum variation sampling. Guided by a socioecological framework, interview data were manually analyzed using an iterative thematic analysis approach. Themes were interpreted across individual, interpersonal, organizational, community, and health system levels. Results: Five interrelated themes characterized BFHI implementation and scale-up in Saskatchewan, including (1) leadership and governance as foundations for BFHI implementation; (2) workforce capacity, competency, and practice consistency as determinants of care delivery; (3) continuity of breastfeeding support across care settings; (4) breastfeeding as a psychosocially embedded maternal experience; and (5) structural and societal factors shaping BFHI scale-up. While supportive leadership, provincial breastfeeding guidelines, skilled healthcare providers, interdisciplinary collaboration, and community-based services facilitated BFHI-aligned care, implementation was challenged by workforce shortages, inconsistent clinical practices, limited access to specialized breastfeeding support, early postpartum discharge, geographic inequities, fragmented care pathways, and inadequate system-level monitoring. Conclusions: In Saskatchewan, BFHI implementation and scale-up are shaped by interconnected organizational, workforce, maternal, and structural factors. The findings provide context-specific qualitative evidence to inform future BFHI planning and implementation. Further research is needed to assess the feasibility, sustainability, and effectiveness of strategies to support BFHI scale-up across diverse healthcare and geographic settings.