**Background:** Exclusive breastfeeding (EBF) is recognized as the optimal feeding method for infants up to six months, offering health benefits for both infants and mothers. The Baby-Friendly Hospital Initiative (BFHI), launched by WHO and UNICEF in 1991 and revised in 2009, was expanded in 2015 by the Nordic and Quebec Working Group to include neonatal wards (Neo-BFHI). The Neo-BFHI comprises Three Guiding Principles (respect for mothers, family-centered care, continuity of care) and Ten Steps to Successful Breastfeeding, plus adherence to the International Code of Marketing of Breast-milk Substitutes. South Africa had an EBF prevalence of 32% at six months in 2016, below the global rate of 38%, and approximately 14% of South African infants are born with low birth weight or prematurity. This study aimed to determine compliance with Neo-BFHI recommendations in South African neonatal wards and compare compliance across levels of care, hospital types (public vs. private), and BFHI accreditation status.
**Methods:** A cross-sectional survey was conducted using the Neo-BFHI Self-Assessment questionnaire, which included 63 indicators scored on a 5-point Likert scale (0–100) or yes/no (100/0). The questionnaire was distributed via EasyTrial online software to neonatal ward representatives who granted goodwill permission. Data were collected from August 31 to December 31, 2017. Country partial scores were computed as medians of 14 ward partial scores (three Guiding Principles, Ten Steps, Code), and overall scores were derived from ward overall scores. The Chi-square test was used for comparisons, with statistical significance defined as p < 0.05. Out of 356 identified neonatal wards, 126 hospital authorities consented, 69 granted goodwill permission, and 33 returned completed questionnaires (response rate 48%). The sample included 26 private hospital wards and 7 public hospital wards (1 level 1, 2 level 2, 4 level 3 facilities). All private hospitals were level 3 facilities.
**Key Results:** The overall median compliance score for South Africa was 77. Public hospitals scored higher (85) than private hospitals (74). Level 2 facilities had the highest median score (92), followed by level 1 (89) and level 3 (75). Among the Guiding Principles, GP 1 (respect towards mothers) had the highest compliance score (100), GP 3 (continuity of care) scored 92, and GP 2 (family-centered care) scored 82. Among the Ten Steps, Step 5 (breastfeeding support/initiation and maintenance) had the highest score (90), and Step 6 (exclusive breastfeeding) scored 88. The lowest scores were Step 7 (mother-infant togetherness) at 58 and Step 4 (kangaroo mother care) at 71. Level 3 facilities scored lowest on Step 4 (67) and Step 7 (50). The Code compliance score was 82. Eight wards (27%) were in BFHI-accredited hospitals, with an overall mean compliance of 91, compared to 73 in non-accredited hospitals. In BFHI-accredited public and private hospitals, compliance was 91, versus 73 (public) and 72 (private) in non-accredited facilities. A significant difference was found between public and private hospitals for Step 5 and Step 6 compliance (p = 0.02), and a significant relationship existed between BFHI accreditation and Step 6 (p = 0.03). Step 7 scores differed significantly between public and private hospitals (p = 0.02), but BFHI accreditation did not significantly influence Step 4 or Step 7 scores (p > 0.05). No significant difference was found between public and private hospitals for GP 1 (p = 0.72) or GP 3 (p = 0.23).
**Clinical Implications:** The overall compliance score of 77 indicates that South African neonatal wards have implemented Neo-BFHI recommendations to a moderate-to-high degree, matching the international median from a 36-country survey. The high scores on GP 1 (respect) and Step 5 (breastfeeding support) suggest that national policies such as the Patients' Rights Charter and the Tshwane Declaration may have positively influenced breastfeeding practices. However, the low scores on Step 4 (kangaroo mother care) and Step 7 (mother-infant togetherness) represent critical gaps, particularly in level 3 and private facilities. These are actionable areas for quality improvement. The finding that public hospitals outperformed private hospitals, despite common perceptions of better resources in private settings, suggests that BFHI accreditation (more common in public hospitals) drives compliance. The authors recommend expanding BFHI accreditation to all non-accredited facilities, especially private hospitals, and developing targeted strategies to improve compliance in level 3 neonatal wards. Limitations include a low response rate (48%), potential self-assessment bias, and a small number of level 1 and 2 wards, which may limit generalizability.